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Barriers to Addressing the Social Determinants of Health:Insights from the Canadian Experience

Dennis Raphael, Ann Curry-Stevens, Toba Bryant


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Abstract

Despite Canada’s reputation as a leader in health promotion and population health,

implementation of public policies in support of the social determinants of health has been

woefully inadequate. The continuing presence of income, housing, and food insecurity has led to

Canada being the subject of a series of rebukes from the United Nations for failing to address

child and family poverty, discrimination against women and Aboriginal groups, and most

recently the crisis of homelessness and housing insecurity. In this article we consider some of the

reasons why this might be the case. These include the epistemological dominance of positivist

approaches to the health sciences, the ideology of individualism prevalent in North America, and

the increasing influence on public policy of the marketplace. Various models of public policy

provide pathways by which these barriers can be surmounted. Considering that the International

Commission on the Social Determinants of health will soon be releasing its findings andrecommendations, such an analysis seems especially timely.

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Introduction

Despite Canada’s reputation as a leader in developing and promoting health promotion

and population health concepts, implementation of public policies in support of health has been

woefully inadequate (Canadian Population Health Initiative, 2002). The continuing presence of

income, housing, and food insecurity among Canadians has led to Canada being the subject of a

series of rebukes from the United Nations for failing to address child and family poverty,

discrimination against women and Aboriginal groups, and most recently the crisis of

homelessness and housing insecurity (D Raphael, 2007c).

The contrast between words and actions has also been apparent in the area of the social

determinants of health (D Raphael, 2007a). Canada’s rich history of policy declarations

regarding the importance of public policy for addressing the economic and social conditions

underlying health has contributed to the social determinants of health concept (Epp, 1986; HealthCanada, 2001; Lalonde, 1974). Canadians have been chosen to manage two of the International

Commission on the Social Determinants of Health’s knowledge hubs and Canadians are making

significant contributions to various aspects of the Commission’s mandate (World Health

Organization, 2004).

Yet on the ground, living conditions continue to deteriorate for many Canadians (D

Raphael, 2007a, 2007c; United Way of Greater Toronto & Canadian Council on Social

Development, 2002). As just one example, Statistics Canada recently reported that over the past

ten years the only group of Canadians showing income gains has been the top 20% whose

incomes have increased substantially (Murphy, Roberts, & Wolfson, 2007). The incomes of the

other 80% of Canadian have stagnated. Analyses of Canadian failures to address the social

determinants of housing, employment security, food security, social exclusion, and poverty –

among others – are available (D. Raphael, 2004; D Raphael & Bryant, 2006).

Considering the accumulating knowledge of the importance of the social determinants of

health and Canada’s reputation for considering these issues on a conceptual level, how can we

explain Canada’s public policy failure to address these issues? In this paper we consider two key

questions. Considering what is known about these social determinants of health and their

importance for promoting the health of Canadians, why does there seem to be so little action

being undertaken to improve them? and (b) What are the means by which such public policy

action in support of health can be brought about? Such an analysis seems especially timely what


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with the International Commission on the Social Determinants of Health coming closer to

offering its sets of reports and recommendations. What might be the barriers to having its

findings and recommendations accepted?

Identifying the Issues

Our analysis considers issues that are only sporadically discussed in the health sciences

literature but appear especially important to implementing strengthening the social determinants

of health agenda. The first issue considers the role that professional and societal discourses –

ways that health professionals, the public, and policymakers understand and consider an issue –

play in having a concept such as the social determinants of health taken seriously (Bryant, 2002;

Nettleton, 1997; Tesh, 1990). What are the ideas about health and illness – the ideologies -- held

by health professionals, the public, and policymakers concerning the sources of health and

causes of disease? How do these ideas influence receptivity to a social determinants of health

approach to promoting health?

This analysis is important as there are numerous aspects of a social determinants of health

approach that are foreign to traditional ways of thinking about health issues in North America.

Some of these aspects include (a) how issues in the health sciences in general, and in

epidemiology in particular, are generally conceived and acted upon; (b) the role that the belief in

individualism and individual responsibility play in North American society; and (c) theincreasing market orientation of North American society and how this emphasis weakens support

for a social determinants of health approach to promoting health.

The second issue is concerned with what is known about the policy change process in

Canada and other developed nations. There are varying approaches to understanding the policy

change process (Brooks & Miljan, 2003). The pluralist approach sees policy development as

driven primarily by the quality of ideas in the public policy arena such that those judged as

beneficial and useful will be translated into policies by governing authorities The materialist

approach is that policy development is driven primarily by powerful interests who assure their

concerns receive rather more attention than those not so situated. In Canadian society these

powerful interests are usually based in the economic market sector and have powerful partners in

the political arena. The public choice view of policymaking tries to get into the heads of

policymakers to understand why they move on some issues and not others. Each approach


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provides differing explanations for understanding the present situation and each proposes

different means of moving a social determinants of health agenda forward.

The pluralist approach suggests the need for further research, knowledge dissemination,

and public policy advocacy with the aim of convincing policymakers to enact health-supporting

public policy (Wright, 1994). The materialist model suggests the need for developing strong

social and political movements with the aim of forcing policymakers to enact health-supporting

public policy. The public choice model has little to say about raising these issues but can be

drawn upon to develop ways of understanding and influencing policymakers’ decision processes.

The third issue is the increasing influence of neo-liberal market-oriented ideology upon

the making of Canadian public policy (Teeple, 2000). The last two decades has seen a

diminishing role of the State in citizen provision of resources. This has been associated with

program reductions, limiting eligibility for a range of benefits, and a shifting of influencetowards the business sector rather than institutions associated with civil society (Hofrichter,

2003). Such shifts have been associated with public policymaking that has little to say about

strengthening the social determinants of health (McBride & Shields, 1997). We consider each of

these in turn followed by suggestions on how these influences can be neutralized such that public

policy in support of the social determinants of health can be developed.

Ideology, Health Discourses, and the Social Determinants of Health

Most of the public probably believes that academic disciplines such as the health sciences

and their applied expressions, public health agencies and governmental health ministries, carry

out their activities based on objective facts drawn from empirical research studies. Within this

framework we would understand the health field’s current preoccupation with biomedical

advances and with what sociologist Sarah Nettleton (Nettleton, 1997) calls the “holy trinity of

risk” of tobacco, diet, and physical activity as reflecting the accumulated evidence that these

domains are the primary determinants of citizens’ health status in developed nations. We would

also understand the profound neglect by the health sciences, public health, and governmental

health authorities of the social determinants of health in Canada as reflecting a lack of evidence

these issues play an important role in determining the health status of Canadians.

Clearly, the evidence concerning the importance of the social determinants of health does

not support this argument (Davey Smith, 2003; Marmot & Wilkinson, 2006; D. Raphael, 2004;


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Wilkinson & Marmot, 2003). There must be more to this neglect of the social determinants of

health than meets the eye and indeed, numerous hypotheses are available to inform this analysis.

The first concerns the nature – that is the focus and the analytical tools available – of research

and action in the health sciences in general and epidemiology in particular.

The characteristics of traditional health sciences and epidemiological approaches that are

problematic have been identified (Bezruchka, 2006; D. Raphael & Bryant, 2002; Tesh, 1990).

These include (a) reliance on quantitative and statistical approaches to understanding health and

its determinants; (b) a tendency towards viewing the sources of health and illness as emanating

from individual dispositions and actions rather than resulting from the influence of societal

structures; (c) a professed commitment to objectivity or what is termed a non-normative

approach to health issues; and (d) a profound de-politicizing of health issues. All of these reflect

an adherence to positivist science as the preferred means of understanding health and itsdeterminants (J Wilson, 1983).

The health sciences in general and epidemiology in particular are a reflection of what has

been termed positivist science (J Wilson, 1983). Positivist science is based on a natural sciences

approach associated with the rise of physics, chemistry, and biology as areas of study. It is

focused on the concrete and observable. It has also been called a reductionist approach whereby

effort is expended to identify specific variables that can be placed into statistical equations in

order to identify putative causes and effects. While positivist science has led to impressive

advances in the natural sciences, its application to the fields of the health sciences and other

areas of social inquiry has been problematic (D. Raphael & Bryant, 2002).

When applied to the health and social sciences, positivist science generally avoids

dealing with aspects of broader environments (Lincoln & Guba, 1985). In the medical field it

leads to a focus upon cells, body organs, and bodily systems by biomedical researchers and a

focus on behavioural risk factors by health sciences researchers (Bezruchka, 2006; Labonte,

1993). The study of environments and the political, economic, and social forces that shape the

quality of these environments is generally neglected (Navarro, 2004). Examination of, and

attention to environments and the public policies that shape these environments – including the

social determinants of health -- is uncommon (D Raphael & Bryant, 2006). Positivist health and

social science also avoids analysis of the abstract, implying the study of the underlying

economic, political, and social structures of society are beyond its analytical and methodological


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grasp (J. Wilson, 1983). The role of politics and political ideology in shaping these environments

therefore, is especially uncommon though excellent examples do exist (C. Bambra, 2004; Clare

Bambra, Fox, & Scott-Samuel, 2005; Navarro, 2002, 2007; Navarro & Muntaner, 2004).

Another important aspect of positivist science is its professed commitment to objectivity

(J Wilson, 1983). This leads to researchers and workers being unwilling to make what are

termed “normative” judgments as to what “should be” as opposed to describing “what is.” This

professed commitment to objectivity and avoidance of normative judgments is a pretense as all

health science researchers and public health workers identify their clear commitments to

promoting treatments regimens to improve biomedical markers and to reduce so-called risk

behaviours such as tobacco and excessive alcohol use, physical inactivity, and diets lacking fruits

and vegetables. These commitments to the importance of biomedical markers and behavioural

risk factors and the neglect of broader issues is so strong as to constitute in itself a normativeideology of what is a health issue and what is not (Hofrichter, 2003; Tesh, 1990). This is -- by

any analysis -- not an “objective” approach to understanding and promoting health.

The professed commitment to objectivity therefore, serves as a means to avoid

consideration of broader issues concerned with political, economic, and social issues. Also

unlikely to be discussed is how the class biases of health researchers and workers come to

influence what is conceived as being either within -- or outside -- the realm of health sciences

inquiry (Muntaner, 1999). A perceived threat to career prospects that may arise by raising

broader issues associated with the social determinants of health is also not to be dismissed (D

Raphael, 2003). Extensive discussions of how these issues shape the health sciences and public

health sectors’ apparent unwillingness to consider a social determinants of health approach are

available (D. Raphael, 1998, 2002; D Raphael, 2003).

Within the traditional health sciences approach, health problems remain individualized,

localized, de-socialized, and de-politicized (Hofrichter, 2003). Notice that such an approach is

congruent with conservative and neo-liberal political ideology – whereby social problems are

being continually framed as individual ones rather than societal ones (e.g., unemployment,

poverty and racism, etc.). Policy solutions under conservative and neo-liberal ideologies are

residual and de-socialized. This means that government support to deal with the fall-out of

social problems is continually eroded as exemplified by the increasing ineligibility of many

Canadians to access unemployment insurance or increasing difficulty students experience in


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financing their education. Frequently, these developments are explicit such as outright

cancellation of progressive policies or social policy or these are done by stealth, meaning

programs become prey to initiatives such as claw-backs, de-indexation or incremental cuts.

While traditional health science approaches may not be overtly conservative in orientation, they

are congruent with such an ideology and serve to justify the retreat of governments around the

world from investing in our collective health and well being (Coburn, 2004, 2006a; Hofrichter,

2003; D Raphael, 2006b; D Raphael & Bryant, 2006; Seedhouse, 2003).

Individualism and the Social Determinants of Health

The second barrier to having a social determinants of health approach taken seriously by

professionals, the public, and governmental policymakers is the North American commitment to

the ideas of individualism and individual responsibility as opposed to communal responsibility(Hofrichter, 2003). Individualism is the belief that one’s place in the social hierarchy – their

occupational class, income and wealth, and power and prestige as well as the effects of such

placement such as health and disease status – comes about through one’s own efforts (Travers,

1997). At the very minimum it leads to placing the locus of responsibility for one’s health status

within the motivations and behaviours of the individual rather than health status being a result of

how a society organizes its distribution of a variety of resources.

The importance of individualism to understanding how the determinants of health are

conceptualized has been thoughtfully explored by Hofrichter:

Individualism, a powerful philosophy and practice in North American, limits the public

space for social movement activism. By transforming public issues into private matters

of lifestyle, self-empowerment, and assertiveness, individualism precludes organized

efforts to spur social change. It fits perfectly with a declining welfare state and also

influences responses to health inequities. From this perspective, each person is self

interested and possessed of a fixed, competitive human nature. Everyone has choice and

the potential for upward mobility through hard work—ignoring how we develop

through the process of living in society. Individualism presumes that individuals exist in

parallel with society instead of being formed by society (Hofrichter, 2003) p. 28).


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Individualism in health has numerous effects in relation to the social determinants of

health. First, it leads to a strong bias towards understanding health problems as individual

problems rather than societal ones. Second, it specifies the cause of the health problem as

residing within faulty biomedical markers, specific individual motivations, and risk behaviours

that are somehow under individual control. Third, it specifies that improving health will result

from modifying these markers, motivations, and behaviours. Fourth, it says little about

reorganizing society and its structure in the service of health. Fifth, it says even less about how

such societal structures could be modified.

An alternative paradigm for understanding health and its mainsprings is available.

Sociologists and social epidemiologists working in the historical materialist tradition have long

attempted to illuminate how various modes of production, especially in capitalist societies,

influence the distribution of economic, social, and political resources within the population,thereby influencing health (see (D Raphael, 2006a). Despite this long-standing tradition, these

analyses concerning the structural determinants of health—and their clear impacts on health --

remain outside the mainstream of current discourse on determinants of health among

policymakers and health researchers in Canada. It is unclear whether the efforts associated with

the International Commission on the Social Determinants of Health can reverse this tendency.

Increasing Market Orientation of Canadian Society

Finally, the increasing market orientation of Canadian society weakens support for a

social determinants of health approach to promoting health.(Coburn, 2004; Scarth, 2004; Teeple,

2000) The rise of capitalism and the market economy grew in tandem with a strong belief in

individualism and the ability of the individual to control one’s destiny (Esping-Andersen, 1990).

The uncritical belief in this ideology was associated with the rise of market-oriented societies

which saw little role for governmental or state intervention in the market place and in the

provision of various forms of security for its citizens. At its heyday such a belief saw the rise of

tremendous inequalities in wealth and health in Victorian England, for example, and more

recently during the 1930s and since the 1970s in many developed nations (Alesina & Glaeser,

2004).

The rise of differing forms of welfare states in Europe during the 19 th century was a


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response to these excesses of laissez-faire capitalism (Esping-Andersen, 1990). In continental

Europe a conservative form of the welfare state arose whose main concern was with reducing

unrest and promoting a modicum of security for citizens. The dominant ideological inspiration

of this type of welfare state has been identified as Solidarity achieved through social stability,

wage stability, and social integration (Saint-Arnaud & Bernard, 2003).

In Scandinavia the social democratic welfare state arose which saw active promotion of

equality and human rights and the provision of citizen security across the life span (Esping-

Andersen, 1985). There, the dominant ideological inspiration is Equality achieved through the

reduction of poverty, inequality, and unemployment (Saint-Arnaud & Bernard, 2003). The third

form of the welfare state – the liberal – was the weakest of all and Canada falls within this group.

In the liberal welfare state the dominant ideological inspiration is Liberty achieved through

minimizing governmental interventions, and minimizing so-called “disincentives to work” suchas social programs and supports.

The liberal welfare state and its associated ideology provide barren soil for a well-

developed social determinants of health approach. Within such an approach, liberty and its close

neighbor, self-determination, become available only to a narrow band of the population – those

who have sufficient financial resources and cultural capital to define their own living conditions

(Coburn, 2006b). Liberty and self-determination are out-of-reach for much of the population.

Scholarship has specified the mechanisms by which these differing forms of the welfare

states developed and how their trajectories shape the making of public policy (Esping-Andersen,

1990). Importantly, these differing forms of the welfare state have been shown to be related to

clear differences in the quality of numerous social health determinants of health and population

health outcomes (Esping-Andersen, 1999; Navarro et al., 2004).

Even so, the end of the Second World War saw a clear desire by all nation states to avoid

the economic and social conditions that gave rise to totalitarianism (Teeple, 2000). Attention to

promoting citizen security was increased across all developed nations such that by the 1970s the

Canadian welfare state was seen by some as rivaling that of Sweden at the time.

Yet the rise of what has been termed neo-liberalism – or a retreat from government

intervention in the marketplace -- has threatened these social reforms (Coburn, 2004; Teeple,

2000). This has especially been the case in the liberal political economies such as Canada. Neo-

liberalism refers to the dominance of markets and the market model. According to Coburn


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(2000), the primary tenets of neo-liberalism are: 1) markets are the best and most efficient

allocators of resources in production and distribution; 2) societies are composed of autonomous

individuals (producers and consumers) motivated chiefly or entirely by material or economic

considerations; and 3) competition is the major market vehicle for innovations. Such ideology

sees little space for governmental action in strengthening the social determinants of health.

Conservative and social democratic political economies have been more able to resist

these forces than liberal political economies (Vandenbroucke, 2002). Consistent with this view,

it has been argued that Canadian society is moving more and more towards that of the most

extreme liberal welfare state, the United States (Scarth, 2004). It should therefore not be

surprising that implementation of a social determinants of health approach has been lacking in

Canada (Canadian Population Health Initiative, 2002). Those attempting to raise these issues

through the provision of evidence and policy options run smack into resistance driven byideological beliefs concerning the nature of society as well as concrete pressures to resist such an

agenda. Some of these concrete forces become clearer in the following examination of how

public policy is made in nations such as Canada.

Understanding Policy Change

Another key issue is the policy change process in Canada and other developed nations.

There are varying approaches to understanding the policy change process (Brooks & Miljan,

2003). The pluralist approach sees policy development as driven primarily by the quality of

ideas in the public policy arena such that those judged as beneficial and useful will be translated

into policies by governing authorities. An alternative materialist approach is that policy

development is driven primarily by powerful interests who assure that their concerns receive

rather more attention than those not so situated. The public choice model tries to get into the

heads of policymakers and focuses on the process by which they develop and implement policies

that maximize the benefits to society (Brooks & Miljan, 2003).

Each approach provides differing explanations for understanding the present situation and

each proposes different means of moving such an agenda forward. As noted the social

determinants of health appear to be underdeveloped in Canada as compared to most other

developed nations. Much of this has to do with public policies that determine how the resources

of the nation are to be distributed among the population.


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Pluralist View

The pluralist view is that public policy decisions result from governments and other

policymakers choosing public policy directions based on the competition of ideas in the public

arena (Brooks & Miljan, 2003). This competition of ideas according to this view is facilitated by

various interest groups who lobby governments to accept their position. Pluralists recognized

that there may not be a level playing field in these lobbying attempts with political, economic,

and social elites having an upper hand. Nevertheless the pluralist approach assumes that the

governmental policymaking process is generally open and those with the better ideas will come

to see their views adopted by governments.

Additionally, pluralists assume that policymaking is a democratic and rational process

whereby the best ideas are put into practice. Individuals, communities, agencies, organizedgroups, labour and business all have a place at the policymaking table. Canadian governments

are not seen as being the handmaiden of the elites. Rather they strive to implement the Canadian

constitutional principles of peace, order, and good government by implementing reasonable

public policy. If Canada lags behind in social determinants of health supportive policy, it

requires education of policymakers and lobbying of these same policymakers with the

expectation that with the right knowledge dissemination, translation, or exchange, these health

supportive policies will come to pass. The pluralist view argues therefore that advocates of the

social determinants of health view need to get organized and have their voices heard by

policymakers. Ongoing consciousness raising, advocacy and lobbying and building coalitions

will achieve policy change.

Taking this view at face value, we would expect that all of the policy recommendations

presented by various Canadian writers would be of interest to policymakers (Campaign 2000,

2004a, 2004b; Canadian Association of Food Banks, 2005; D. Raphael, Bryant, & Curry-

Stevens, 2004; Dennis Raphael & Curry-Stevens, 2004). The only problem is that these policy

options have been presented numerous times over the past decade to policymakers, their benefits

have been outlined repeatedly, yet no action seems forthcoming. For example Raphael and

Curry-Stevens suggested a number of options that would strengthen the social determinants of

health (see Table 1).

Yet, there is little evidence that any of these recommendations have been taken seriously. Why is


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this the case? Perhaps we need an alternate model of policy change to explain the current

situation and point the way forward. The materialist model provides such an alternative.


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running for the dominant political parties may either come from the business class and/or hold

values. These individuals can not only expect to receive financial support for their runs at

political office, but can also be assured of employment opportunities within these same sectors if

they fail to be re-elected or upon their retirement from public office (D Raphael, 2007b).

Increasing income and wealth inequality and the weakening of social infrastructure result

from the concentration of wealth and power within a nation with attendant weakening of civil

society (Phillips, 2003; D Raphael & Bryant, 2006). What is to be done? The materialist model

suggests organizing the population to oppose and defeat the powerful interests that influence

governments to maintain poverty (Wright, 1994). These defeats can occur in the workplace

through greater union organizing and the promotion of class solidarity. These defeats can occur

in the electoral and parliamentary arena by the ascendance of working class power.

This would come about by achieving greater equity in political power (Zweig, 2000).This can be achieved by restoring programs and services and reintroducing more progressive

income tax rates. Independent unions are a necessity as is legislation that strengthens the ability

of workers to organize. Re-regulating many industries would reverse current trends towards the

concentration of power and wealth. Internationally, the development and enforcement of

agreements to provide adequate working and living standards that would support and promote

health and well being across national barriers is essential.

The provision of a social wage—government provided services that people need to live

and develop their ability to work—is a way to restore the social infrastructure that has been so

weakened in nations such as Canada. Resistance to the privatization of public services is

essential.

Public Choice Model

The public choice model focuses on the individual policymaker and the process by which

they develop and implement policies that maximize the benefits to society (Brooks & Miljan,

2003). In this model the policymaker looks out society’s as well as his or her own interests by

balancing the interests of a wide range of stakeholders: various interest groups including

business, labour, the needs of elected officials and senior civil servants, and the media, among

others. The public choice model would suggest that it is not in the overall interests of Canadian

policymakers to address the social determinants of health. People who experience poor quality


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determinants have little influence with policymakers since their concerns are not seen as being

the concern of most Canadians, and in any event these people are less likely to vote. In contrast

those interests who experience weak social determinants, these interests are highly organized, are

able to exert influence upon policymakers, thereby controlling the public policy agenda. Put

simply, raising and addressing social determinants of health issues provides little benefit for

governing parties. The public choice model argues that policy dynamics must change such that

policymakers who do not address poverty will suffer consequences and their political masters

will experience electoral consequences.

The Way Forward

Such an analysis suggests that what is necessary to promote governmental receptivity to

the social determinants of health concept is the building of social and political movements insupport of health. There is some evidence that the social determinants of health concept has

contributed to this. Numerous Canadian social development and social justice advocacy groups

as well as public health units have taken up the social determinants of health concept in support

of their activities (Association of Ontario Health Centres, 2007; Chronic Disease Alliance of

Ontario, 2007; Interior Health Region, 2006; O'Hara, 2006; Registered Nurses Association of

Ontario, 2007; Sudbury and District Health Unit, 2006; Waterloo Region Public Health Unit,

2002).

In this section we focus on what role health researchers and workers could play in this

public policy arena. These three roles are education, motivation, and activation in support of the

social determinants of health. These roles are about building the social and political supports by

which public policy in support of the social determinants of health could be implemented. Each

is considered in turn. As noted, such action will require broadening of knowledge paradigms in

the health sciences, accepting the political nature of health and its determinants, and confronting

many of the economic and social forces that are opposed to governmental action in the service of

strengthening the social determinants of health.

Educate

In Canada and other nations governed by liberal political economies, the public remains

woefully uninformed about the social determinants of health (Canadian Population Health


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Initiative, 2004; Eyles et al., 2001; Paisley, Midgett, Brunetti, & Tomasik, 2001). The population

has also been subject to continuous messaging as to the benefits of a business-oriented laissez-

faire approach to governance (Teeple, 2000). What this messaging has not included are the

societal effects of this approach: increasing income and wealth inequality, persistent poverty, and

a relatively poor population health profile (Coburn, 2006). These effects are profound and

objectively influence – for the worse – the health and well-being of a majority of the population

(Esping-Andersen, 1999).

There are hundreds – if not thousands – of Canadians whose occupations are concerned

with the health of the public. These workers could take advantage of the citizenry’s continuing

concern with health and the wealth of evidence of the importance of the social determinants of

health to begin offering an alternative message to the dominant biomedical and lifestyle

discourse. At a minimum health promoters can carry out – and publicize the findings from --critical analysis of the social determinants of health and disease. This is not a question of being

subversive – it is rather a simple matter of information and knowledge transfer.

There is no shortage of areas in which health researchers and workers could engage:

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 (G

Davey Smith, 2003). Our 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 (Raphael, 2002; Raphael,

Anstice, & Raine, 2003).

Motivate

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 (Popay & Williams, 1994). There is some indication that policymakers – and certainly the


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media – may be responsive to such forms of evidence (Bryant, 2002). In Canada, such research

clearly constitutes a small proportion of public health and health services research (Raphael,

Macdonald et al., 2004).

There is increasing recognition of the importance of community-based research and

action (Minkler, 2005; Minkler, Wallerstein, & Hall, 2002). But frequently, these activities are

narrow and seem unwilling to allow citizens to raise issues of public policy concerned with

income distribution, employment and labour issues, and fundamental questions of citizen

participation in governmental priorities and actions. Such activities can be a rich source of

insights about the mainsprings of health and means of influencing public policy. Such a

perspective allows community members to provide their own critical reflections on society,

power and inequality. At a minimum 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 political activity on their part and policy action on the part of health and

government officials. Ultimately, the end of such activities should be the creation of social

movements in support of health. The People’s Health Assembly is but one example of such a

movement in support of health (People's Health Assembly, 2005).

Activate

The final role 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. It is no accident that nations where the quality of the social determinants of health is high

have had greater rule by social democratic parties of the left. Indeed, among developed nations,

left cabinet share in national governments is the best predictor of child poverty rates which itself

is associated with extent of government social transfers (Rainwater & Smeeding, 2003). 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 hade the highest poverty rates and lowest

social expenditures. Canada, like the other liberal nations of New Zealand, Ireland UK, and the

USA is among the lowest nations in left federal cabinet share (0%) and among the highest in

child poverty rates (15%) in the 1990s (providing a poor poverty standing of 19th of 26 OECD

nations).


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17

It has also been documented that poverty rates and government support in favour of

health – the extent of government transfers – is higher when popular vote is more directly

translated into political representation through proportional representation (Alesina & Glaeser,

2004). Canada also does not have proportional representation – the lack of which is associated

with higher poverty rates and less government action in support of health. Proportional

presentation is important because it provides for an ongoing influence of left-parties regardless

of which party forms the government.

This analysis recognizes the profound barriers that exist in having the Canadian

government address the socials determinants of health. Dominant ideologies typical of the health

sciences, public attitudes towards personal responsibility, and increasing market influence all

work against having a social determinants of health agenda implemented.

Nevertheless, developments in Europe indicate that concerted public health andcommunity efforts can profoundly influence the development of policies that determine the

extent of health inequalities and the overall state of population health within a nation. The policy

directions being undertaken by nations such as Sweden and Finland are two such examples

(Government of Sweden, 2005; Ministry of Social Affairs and Health, 2001). Similarly, the

success of the WHO European Office Healthy Cities initiative is another example of the power

of cities and communities to influence health policy (World Health Organization Regional Office

for Europe, 1997, 2003). Canada has a rich history of concerted public pressure that can lead to

positive policy change.

The social determinants of health concept can help make the links between government

policy, the market, and the health and well-being of citizens in Canada and elsewhere. For those

working in the health sector, it can serve as motivation for working for change. The interests of

their clients, patients or consumers are served by speaking out against poverty, social exclusion,

inequality, and inadequate services. There are potent barriers however, to such actions. We hope

this article can assist in recognizing and surmounting these barriers.

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Table 1: Policy Options to Support the Social Determinants of Health

Policies to Reduce the Incidence of Poverty

Raise the minimum wage to a living wage.Improve pay equity.Restore and improve income supports for those unable to gain employment.Provide a guaranteed minimum income.

Policies to Reduce Social Exclusion

Enforce legislation that protects the rights of minority groups, particularly concerningemployment rights and anti-discrimination.Ensure that families have suf cient income to provide their children with the means ofattaining healthy development.Reduce inequalities in income and wealth within the population, through progressivetaxation of income and inherited wealth.Assure access to educational, training, and employment opportunities, especially forthose such as the long-term unemployed.Remove barriers to health and social services which will involve under-standing whereand why such barriers exist.Provide adequate follow up support for those leaving institutional care.Create housing policies that provide enough affordable housing of reasonable standard.Institute employment policies that preserve and create jobs.Direct attention to the health needs of immigrants and to the unfavourable socioeconomic

position of many groups, including the particular difficulties many New Canadians face

in accessing health and other care services.

Policies to Restore and Enhance Canada’s Social Infrastructure

Restore health and service program spending to the average level of OECD nationsDevelop a national housing strategy and allocate an additional 1% of federal spending foraffordable housing.Provide a national day care program.Provide a national pharmacare program.Restore eligibility and level of employment benefits to previous levels.Require that provincial social assistance programs are accessible and funded at levels toassure health.Assure that supports are available to support Canadians through critical life transitions.

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sdoh barriers to sdoh nov2007

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