Social Determinants of Health

A Half-Baked article for my weekly column.

The difference between medicine and public health can be illustrated by the analogy of fishes in a pond. Medicine is the study of the fishes while public health is the study of the pond in which the fishes live (they are not water-tight compartments but that is a good way to understand the difference). It is important to study the fishes, their anatomical structures, functions, behavior, etc. in order to care for them and find ways to treat their diseases. But it is also important to study the condition of the pond in which the fishes live; the water salinity, other chemical contents, surrounding vegetations, other organisms that live in the pond, etc.; in order to keep the fishes healthy. Modern health care has been oriented towards biomedical model, concentrated on hospital based curative care. Ill health is presumed to be something that is fixed at the doctor’s chamber. It is only recent that public health perspectives are taking prominence in health policy and programs. It has been shown that biology alone does not explain why people in some countries are expected to live longer than some others by as much as 40 years. Even within countries, life expectancy difference of up to 20 years has been observed between regions. Health is more than the practice of medicine. It is the conditions in which people are born, grow, live, work, and age which greatly determine the status of health of the people. The social and economic conditions that influence the wellbeing of individuals or people groups are called Social Determinants of Health (SDH). Provision of medical care, no doubt, is absolutely necessary. But it is only one of the many determinants of health, accounting to about 15% of the determinants of wellbeing. In places where health care facilities are inadequate, the lack of health care facilities itself becomes a social determinant. In Nagaland, variations do exist in the health status between rural and urban population which has nothing to do with difference in biology between rural and urban people. Such differences in health status between tribes, gender, and socio-economic classes are evident. Access to services also differs that according to the National Family Health Survey III (2005-06), 54.3% of mothers in urban areas had birth assisted by a doctor or trained health personnel while it is only 17.9% for rural mothers in Nagaland. Immunization, treatment of childhood diseases, use of modern family planning methods, access to electricity, toilet facility, information, etc. are all higher for the urban areas than the rural according to the survey. The WHO’s Commission on Social Determinants of Health, 2008 says that such health inequities between regions, people groups, gender, or social classes are matters of social justice, ‘where systematic differences in health are judged to be avoidable by reasonable action (and) they are, quite simply, unfair’. In India, The Planning Commission set up a High Level Expert Group to advise on Universal Health Coverage for India. SDH was not included in the original terms of reference, but the group felt that SDH is crucial to achieve Universal Health Coverage target in India. So, in the report (2011), an entire chapter was dedicated to it. The rationale to include SDH was stated as, ‘The need for action on social determinants emerges from the recognition that there are huge differentials among and between classes and castes, gender gaps and wide regional variations in both disease burden and response by the health system and others concerned with development’. Malnutrition, lack of water and sanitation, and social exclusion, are detrimental to human health. Malnutrition in early years of life has a bearing on the health status later on in life. Water supply and toilet facilities are important for prevention of communicable diseases like typhoid, acute diarrheal diseases, cholera, viral hepatitis, malaria, etc. The expert group also cites that in rural India, women are three times more likely to go without treatment for long-term ailments, and when they do, money spent on treatment is less than that of men. Such gender discrimination and other forms of social exclusion adversely affect health. Therefore to enjoy good health, a concerted effort is required to improve the overall living conditions of the people. In England, the WHO commission on SDH has been adapted into six domains as quoted by Michael Marmott in a WHO bulletin article. These are: (i) give every child the best start in life, (ii) improve education and life-long learning, (iii) create fair employment and jobs, (iv) ensure minimum income for a healthy standard of living, (v) build healthy and sustainable communities, and (vi) apply a social determinants’ approach to prevention. South Australia also adopted a ‘Health in all policies’ approach. In all the policies of the government, be it for housing, rural/urban development, agriculture, security, social welfare, employment, labour, disaster management, etc.; health plans need to be put in place. To carry out any activity in life, good health is essential. The best food is not tasty if one is not healthy to enjoy it. Good music is no music at all if one is too sick to enjoy it. Healthy living conditions along with health services must be ensured. The gaps in distribution of resources between regions and socio-economic and racial groups must be minimized. A public health perspective is needed so that health care goes beyond hospital based medical care. For instance, it is important to know the cause of the diseases, but it is also very important to know the ‘cause of the cause’ of ill health if we want to seek for long term solutions.