Social and Structural Determinants of Health

“Disease is a social and political category imposed on people within an enormously repressive social and economic capitalist system, one that forces disease and death on the world’s people” Vicente Navarro

At the Alliance for People’s Health (APH) the Community Health Worker (CHW) Team and the ‘Smile with Dignity’ Dental Campaign Committee have been discussing and debating the social and structural determinants of health. The social determinants approach defined by the belief that our behaviour and our access to social and economic resources being the foundation of health; the structural determinants approach defined by the viewpoint that it isn’t simply access to resources that determines our health, but goes further to argue that control and ownership over those resources is the ultimate factor in determining individual health and the health of our communities. Perhaps this seems, in appearance, to be a question of semantics, but in essence, it is a significant leap in the strategic approach to projects which purport to be supporting health.

Why have APH members and organizers been so deeply exploring this topic? Because in our experience as a grassroots organization of health workers and health organizers from working class and marginalized communities, it isn’t enough to say that our communities are experiencing higher rates of disease and illness, that we’re more likely to be sick, because we’re poor. It isn’t enough to say that our behaviour is riskier due to ignorance of better choices, or our risk of illness is higher because of the income level of our community. Where does that leave us? This type of social determinants analysis fuels the fad in public health promotion: the social marketing of behaviour-change messages (as if ‘choice’ is a matter of choosing from among equal options), charitable programs and under-funded social programs often end up functioning as another form of social control in poor communities through hoop-jumping and time-consuming rules for participation, or the fad in Vancouver of building supposedly ‘mixed-income’ communities (as if the decades-old trend of ‘mortgage helpers’ has improved the health of the poor families that pay absorbent rents for the privilege of crowding into the basements of the affluent).

Our analysis has to go deeper; we require a radical analysis to root out the problems at the structural level and to direct us toward changes which strike at the heart of health inequalities. The brunt of the matter is that the few have control over the direction of their lives through political, economic and social power, and the many do not.

Pondering the Usefulness of a Social Determinants of Health Approach

The hard facts are that poor communities experience higher rates of illness and injuries, the question that plagues health academics, researchers, and activists is – why? And the answer to the ‘why‘ is the key to ‘what is to be done‘. After much study and discussion, in fact, 14 years of study and discussion, I firmly believe that in isolation of a deeper analysis, the social determinants of health perspective is stunted and leads the health sector down a path of misguided action.

The premise of the social determinants of health is that health is a result of our socio-economic environment, and as such, poor health outcomes are not equally distributed in our fundamentally unequal society. This sounds great initially, but what are the proponents of the social determinants approach really saying? That health status is a reflection of health-supporting (or harming) behaviours, which in turn are determined by our access to the economic and social resources that support us to make better choices.

Following along this path of analysis, if health is determined by our access to resources, than the answer is to increase the access of the poor to things like education, housing, and childcare. The logical response to this viscous cycle of poverty-illness-poverty is to create targeted social programs in poor communities.

Unequal Distribution of Ill Health in the Philippines: A Basic Analysis

Consider some facts about health and disease in the Philippines. The WHO reports some improvement in maternal and infant mortality rates, an important reflection of the overall health of a society. However, as IBON points out, these statistics are aggregate for the entire population, and don’t reflect the realities in inequalities between the ruling elite and the peasant farmers, agricultural workers such as the Sacadas, or sugar workers, and workers in the informal economic sectors (vendors, street sweepers, street children, garbage dump scavengers, etc.).

Aggregate health indicators aside, the real-life situation for the vast majority of Filipinos, the 70% of the population that survives on Php 86/day (about $2 Cdn), continues to worsen under economic crisis.

I quote from IBON here: “slowing improvement – and in some cases reversals [of health status indicators] – is very much a direct consequence of the barrier to further improvement that rising poverty and inequality creates and of the worsening government neglect of health” (Chronically Ill: An Overview of the Philippine Health Sector, p. 21).

In reality, despite programs targeted to improve the health of the poor, little has changed in the past several decades:

• Preventable and/or curable infectious diseases remain 3 of the top 5 causes of death in children ages 1 – 4: pneumonia, accidents, diarrheas & gastroenteritis, measles, and congenital anomalies. Overall morbidity rates reveal that infectious diseases continue to account for the primary causes of morbidity (pneumonia, diarrhea, bronchitis, influenza, respiratory TB, dengue fever, malaria, and chicken pox).
• Chronic diseases continue to rise, inextricably linked to morbidity and mortality from infectious causes in a dialectical pattern of disease; malnutrition, nutrient deficiencies, untreated oral disease, toxic and environmental exposures, long and arduous working hours, stress, and low resistance exacerbate hypertension, diabetes, and heart disease, and are often compounded by co-morbidities of infectious origin such as skin or urinary tract infections, respiratory TB, pneumonia, and gastroenteritis and diarrhea. The perspective that development is reflected in a shift from infectious to chronic disease is not evidence-based.
• 57% of households have inadequate nutritional intake, the equivalent of 10 million households. This means that the majority of children are susceptible to malnutrition, and subsequently have lowered resistance to morbidity and mortality from infection. In Western Visayas (Negros Occidental) 30-40% of children are underweight or under-height. Iodine deficiencies, Vitamin A deficiencies, and iron deficient anemia persist at high levels despite government programs to provide micro-nutrient supplementation in rural areas. Pregnant women continue to have high rates of iodine deficiencies and anemia despite the social marketting of behaviour-change messages.

WHO statistics estimate that 6.6 percent of children in the lowest income bracket in Western Visayas dies before reaching their fifth birthday. Now let’s ask, why?

Diarrhea as a Case Study in Lack of Economic and Political Control

Given the state of medical science and the human capacity for development, if a child dies from diarrhea, let’s ask, “Why did this happen?”

The bio-medical model of disease points to pathogens contracted by the child that creates infection in the gastrointestinal tract that lead to dehydration and eventually, if not treated with a medical intervention, to death.

A behavioural approach points to the behaviour of the child and thus ultimately of the parents in the cause of a child’s death. Behaviours such as not washing hands after defecating and not bathing regularly, and not keeping a clean household contribute to diarrheal diseases. It is likely that lack of personal and household hygiene contributed to the contamination with pathogen that was the source of a child’s illness.

A social determinants approach would look deeper than the pathogenic and behavioural factors; true enough that contracting a gastroenteritis does not lead to death without multiple contributing factors. Perhaps once the child was ill the parents were uncertain about how to take care of the child, and did not use oral re-hydration, offer clean water to drink, or offer the child enough to eat. 30% of under-five deaths are ultimately attributable to malnutrition irregardless of the pathogen that was the cause of death; malnourishment is all-too-frequent and compounds diarrheal and other diseases.

A structural approach to the determinants of health argues that, ultimately, the inability of the parents of this child to have economic and political control over their circumstances led to the child’s death. The parents did not have the ability to determine for themselves the conditions of their daily lives, the source of their livelihood, and sustenance upon which they were forced to survive. As one health worker explained to us, the children of the marginalized have no hope, they do not dare to dream to be doctors or teachers; when you ask the children of the rural and urban poor what they dream to be, they can give no answer, for from a very tender age they are acutely aware they have no control over their future.

There exists a complex of behavioural, social, and structural factors that determine health status. Yet, the structural factors are the base from which communities are able to change or influence the social and the behavioural factors. When communities have control over economic capital, ownership of financial assets, land, and production, and political control over decision-making structures and super-structural institutions, only then will the base conditions that determine health be addressed.

Behavioural and Social Responses to Deaths from Diarrhea

Let’s consider why didn’t this child wash his hands after defecating? Why wasn’t he able to bathe?

In the Philippines, the WHO estimates that approximately 80% of the population has access to a clean water source and between 60-80% live in a dwelling with access to improved sanitation. But even as I read these stats, I think to myself, what does “access to a clean water source” mean? When water must be purchased or boiled with precious fuel, how can we say that not using scarce clean water to wash hands or to frequently bathe a child who will just get grubby again a choice? What are the other choices that are presented to the parents of a child who live in poverty, as 70% of Filipino families do? Even if parents are ‘educated’ and know that feces on the hands transmit disease, or mucus and food scraps on the face attract insects that carry infection, knowledge does not provide clean water to bathe a child.

OK, so why wasn’t the floor of the household kept clean? If a baby crawls through feces, either human or animal, that was tracked into the house on dirty feet or shoes, and then puts her hands in her mouth, that is a source of diarrheal disease. Or a mother picks up her fussy baby, transferring feces from the floor onto her hands, and then prepares the family dinner, then diarrheal disease-causing pathogens are transmitted to the entire family.

How did the WHO gather their statistics on access to clean water and improved sanitation? In our experience, urban poor and rural peasant communities struggle to survive under very difficult circumstances with completely inadequate housing and almost no access to proper sanitation. Even the most diligent family would be hard pressed to prevent the spread of infection in an environment that overwhelmingly facilitates the spread of disease.

Examples of Solutions to the Behavioural-Social Determinants Complex

If our exploration of ‘whys‘ of a child’s death from diarrhea ends with behaviour and basic social factors, possible solutions could involve a) treating diarrhea before it becomes deadly, b) and building more housing and improving access to clean water sources to facilitate proper hygiene.

a) Selective Primary Health Care – Oral Rehydration Therapy

The World Health Organization (WHO) and UNICEF continue to promote ‘selective primary health care’ and the development of social marketing projects to teach communities how to prepare and administer oral re-hydration solutions (ORS) which come from WHO and UNICEF in the form of sealed packets of powdered mix to which clean water must be added. Rather than establish and fund the operation of essential primary care the the community level through Community Based Health Programs that empower the community to collectively tackle the fundamental problems of underdevelopment through participatory projects, WHO and UNICEF employ shallow campaigns. ORS is a great example of a ‘selective’ primary health care program; the development and distribution of ORS packets and social marketting campaigns to promote the use of ORS and zinc supplementation at the community level.

Who benefits from the implementation of selective primary health care at the national and international level? The companies contracted to produce the ORS packets, the companies contracted to develop the marketting campaigns, and so on. I feel sick to my stomach as I write this. After what we’re witnessed, and what we’ve heard from the peasant farmers and the CHWs on their assessments of the roots of the health problems in the country-side, I know from first hand experience that selective primary health care and the distribution of supposed ‘magic bullets’ can do more harm than good.

Here I quote from Questioning the Solution: “It is interesting to consider why UNICEF and USAID have put nearly all their emphasis on packets, and I think the motivations are different. UNICEF needs to be able to say that it has made progress over the short term, to maintain its financial support; and progress, they believe, depends on having an intervention based on a simple discrete countable item, such as vaccines, vitamin A, or packets. USAID, on the other hand, has a social policy based on willingness to pay. Paying for things is what life is all about for them”, further “strong promotion of commercial packets for home use may be indirectly contributing to children’s deaths by leading families to spend on packets what they might otherwise spend on food.”

Plenty of other examples of selective primary health care exist. In response to hunger, NGOs and the WHO distribute products such as Plumpynut, a peanut based high-calorie nutritional supplement for malnourished children, or promote educational programs for nutrition and dietary supplementation in the form of capsules or pills in areas where dietary intake is inadequate to meet nutritional needs. But this is another story, for another time; too much to cover here! (See Questioning the Solution – still a very relevant read!).

b) Build Housing and Improve Access to Clean Water – Gawad Kalinga

In the Philippines, a growing response to the crisis of land and housing, especially in the rapidly expanding urban centres, can be found in the construction of Gawad Kalinga projects.

In Bacolod, Gawad Kalinga (GK) is constructed on land that once was home to over 450 households, urban poor who were evicted. It is planned that another couple of batches of 60 GK houses will be built, but a further 900 plus urban slum-dwellers must be evicted from the land before constructional can begin.

GK is an international NGO with ties to Christian Churches and government aid and development funding, including funding from the Canadian government.

Aiyanas, Billy, Jimmy and I were accompanied by Em2 in visiting a GK in Bacolod so we could witness first hand the kinds of ‘development projects’ that the Canadian government is touting as beneficial for the Philippines. Turns out that GK seems more like a great example of the stunted nature of projects designed to ‘alleviate poverty’ without actually addressing the fundamental conditions which give rise to this shocking level of poverty to being with.

What we saw at GK were 60 duplex houses comprised of a single concrete room measuring approximately 12′ x 12′, a tiny ‘kitchen’ devoid of any appliances, and a teeny-tiny CR (comfort room, or bathroom) comprised of a squat toilet and a drain in the floor. The interior construction of the GK houses was completely up to the residents, who were drawn by lots to receive a space in GK, and then required to work 2500 unpaid hours to qualify for their housing assignment. In the GK homes we visited, the residents had built interior walls and/or loft spaces to maximize the use of space. The average family size living in one GK house seemed to be 6 adults and an assorted number of children. Parents, adult children, and grandchildren all living together, along with aunties, uncles, and cousins.

The lane-way running between the GK houses held open drains (can anyone say dengue fever?) from wash water, and a central pump that was shared among GK members for clothes washing, bathing, and household cleaning. Water bills came individually to families, as did the cost of electricity. Electrical installment was also the responsibility of individual families.

What we heard from those we interviewed was that they were grateful for housing, as inadequate as it was, it was better than the urban slums from where they came. However, what didn’t sit well with any of the residents we interviewed was that 450 families were evicted and yet only 60 were rehoused after providing indentured labour for the construction of the homes. If the land was public or privately donated land, the labour for frame construction was free, and internal construction, electrical hook up and water hook up expenses were born by the residents, then where did the money from international aid actually go?

Many residents also complained that the moral rules enforced by GK amounted to a form of unacceptable social control, and the presence of the Church was generally tolerated, but also questioned. Was this development or charity?

Finally, what we learned from the residents is that the true demands of the urban poor were not reflected in GK ‘development’ projects, nor did these types of projects address the fundamental problems faced by the urban poor. The true demands of the urban poor are for land, adequate livelihood, and living wages.

The Shortcomings of Social Determinants of Health Approach

Neither of the above described programs makes any change in the underlying economic or political structures that create the grossly unequal distribution of disease in our societies and our communities.

The mainstream responses to the evidence that health is socially constructed and that the poor have poorer health than the rich is to make improvements in the conditions within which people live, work, and learn through social programs and charitable operations by which some of the impacts of poverty are attempted to be alleviated.

The four predominant responses to the unequal distribution of ill-health are:

1. Demand the state provide basic services. Pushing the state to redistribute wealth and assist in the alleviation of poverty is an important struggle for working class communities, but many state programs operate as public-private partnerships (PPP), reflect a neo-liberal agenda, or end up operating as another form of social control for poor communities.
2. Charitable operations. Charitable services are often the only avenue that poor people have to meet basic needs when ends don’t meet and social programs are inadequate to fill the gaps. However, there is evidence that demonstrates that charitable services are dis-empowering, and contribute to many problems faced by marginalized communities; GK is an example of this.
3. Private or corporate provision of what used to be public services. Many argue that privatization of public services leads to less expensive delivery of necessary services, reducing government budgets. This is plainly and simply neo-liberal clap-trap. Privatization leads to reduced services to the poor, the implementation of user-fees and cost recovery programs, does NOT amount to a reduction in taxation, and in the end, it is once again the poor that pay. The history of Structural Adjustment Programs (SAPS) in the Third World is a 40 year testimony to this fact.
4. Relying on International NGOs to fill the gaps. NGOs such as Red Cross, Medicines Sans Frontiers, and many others step in to fill the gaps when governments (for a variety of reasons, but generally compounded by debt-servicing on IMF/WB loans, heavy military budgets, and regressive taxation) are not ‘able’ to fund social programs.

But none of these programs, campaigns and services addresses the root of the problem – what creates inequalities to begin with?

Imagine a triangle. It describes the factors that generate inequalities in our society:

The deepest whys are the ones that lead us to the bottom, the roots, the radical answer to the question ‘why?’

Now let’s imagine another triangle, it looks like this:

How can we accept this distribution of wealth, and hence political power in our society? How can we live with this as caring and conscious human beings? How can we accept this and think it’s OK?

Let’s Talk Structural Determinants of Health

“It is not inequalities that kill, but those who benefit from the inequalities that kill.” Vicente Navarro

This is a blog, and so I feel I have the ability to be frank with my thinking without a song and dance to soften my opinions. There are people, actual faces, behind the gross injustices in this world today. People who aren’t going to give up what they’ve got based on some moral arguments or by being ‘made aware’ of the situation they personally benefit from!

These people have a few things in common: decision-making power, be it local, regional, national, international, or institutional; control over capital: land, corporations, capital, factories, workplaces; and some measure of control over the direction of society – politically, economically, socially, culturally, and ideologically.

I find it extremely frustrating that we stop short of a meaningful analysis because we’re too afraid to be ridiculed, labelled socialists and therefor discredited (despite the hard facts that some of the greatest advances in addressing the social determinants of health come from countries with either socialist governments or socialist-leaning social and economic policies), or perhaps because its too hard, too discouraging, too overwhelming to admit that in order to address the gross inequalities in health that exist in the world today we need to have fundamental social and economic transformation.

What exploited and oppressed communities need to have is decision-making power (some might call this participatory democracy), control over financial resources (some might call this socialism), and a reasonable measure of control over the direction of society as a whole.

What would the collectivity of humanity prioritize if we have economic control? Would we give land to the urban poor, or build another mall to line the pockets of Henry Sy, Sr. and company.

If we had political control over the decision-making structures in our societies, what we we elect to do? Would we give tax breaks to Nestle, and overlook their gross violations of human rights as well as their violations of The International Code of Marketing of Breast-Milk Substitutes in the commodification of infant feeding leading to the deaths of millions of babies? Or would we support the Reproductive Rights Bill to provide life-saving reproductive health services to women?

How can we change these things?

When we’re planning public and community health interventions, what we need to do is ask ourselves: Do the interventions that we advocate increase community control for poor and marginalized/working class communities? Do they redistribute wealth from the rich to the poor in a democratic and participatory fashion? If the answer to ‘no’ to these questions, then perhaps we should question the effectiveness, or even the motivations, of our proposed interventions.

But what type of interventions do increase community control and effectively and justly redistribute wealth?

Exploring possible answers to this question is the reason why we’re here in the Philippines. Not only to provide what support we can offer to the Community Based Health Programs, the Community Health Workers, and the People’s Organizations, but also to learn about the rich history and many lessons and successes in building a democratic movement for social transformation in the Philippines. To turn the tide of economic injustices, the struggle must be one for complete change by all means we have at our disposal. It is time as health workers and community organizers, for us to take our place and struggle alongside those who have the most to gain from national and social liberation.

RESOURCES

The Alliance for People’s Health website

UNICEF & WHO “Facts for Life” is a good resource for hygiene and cleanliness recommendations for parents, among other recommendations like diarrhea prevention and treatment.

Questioning the Solution remains relevant 20+ years later, and is an excellent resource on the difference between Community Based Primary Health Care and Selective Primary Health Care – also a great overview of the economics of health.

Vicente Navarro’s article, “What we mean by social determinants of health” is an excellent critique of the World Health Organization’s document on social determinants of health.  International Journal of Health Services, Volume 39, Number 3, Pages 423–441, 2009.