In late 2002, 400 social and health policy experts, community representatives and health researchers from Canada met at York University in Toronto at a confer- ence entitled ”œSocial Determinants of Health Across the Life-Span” to consider the state of ten key social determi- nants of health across Canada, explore the implications of these conditions for the health of Canadians, and outline policy directions to strengthen these social determinants of health. At the same time, Roy Romanow’s Building on Values: The Future of Health Care in Canada was released. Despite submissions to the Commission that stressed the impor- tance of the social determinants of health for the health of the population and maintaining the sustainability of the health care system, there was nary a mention of these issues – in the Commission’s final report, in contrast with Michael Kirby’s report, The Health of Canadians – The Federal Role, released earlier. In this article I will outline why the social determinants of health are so important and consider rea- sons for the continuing gap between what is known about the social determinants of population health and govern- mental action on these issues. I will provide examples of nations that have incorporated thinking about social deter- minants of health into national policy directions.
While there has been profound improvement in health in industrialized nations over the past century, wide disparities in population health continue to exist between nations and among citizens within nations. Some analysts hypothesize that access to improved medical care is responsible for such differences, but best estimates are that only 10-15 percent of increased longevity since 1900 is due to improved care. More recently, differ- ences in lifestyle behaviours such as tobacco use, diet and physical activity have been presented as the prime determinants of health. But studies conducted as early as the mid 1970s, which have been reinforced by numer- ous more recent studies, find these risk factors account for only a small pro- portion of variation in incidence among individuals in heart disease, cancers and diabetes. There are addi- tional factors that predict health and illness. What are these?
Nonmedical and non-lifestyle factors that affect health go by a variety of titles. The ”œOttawa Charter for Health Promotion” identifies the prerequisites for health as being peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. Health Canada accepted direction from the Canadian Institute for Advanced Research in outlining deter- minants of health, many of which are societal determinants. The determi- nants it came up with are income and social status, social support networks, education, employment and working conditions, physical and social envi- ronments, biology and genetic endow- ment, personal health practices and coping skills, healthy child develop- ment and health services.
A World Health Organization working group more recently identi- fied ten social determinants of health: the social [class health] gradient, stress, early life, social exclusion, work, unemployment, social support, addic- tion, food and transport. The organiz- ers of the York University ”œSocial Determinants of Health” conference synthesized these formulations to identify ten key social determinants of health that are especially relevant to Canadians: early life, education, employment and working conditions, food security, health care services, housing, income and its distribution, the social safety net, social exclusion, and unemployment and employment security.
The evidence that these social determinants of health are of more important to the health of Canadians than biomedical and lifestyle factors is clear. As one exam- ple, adverse socio-economic circum- stances during childhood are repeated- ly found to be more potent predictors of the incidence of cardiovascular dis- ease and diabetes than later life cir- cumstances and lifestyle behaviours, facts not touched upon by the Romanow, Kirby or Manzankowski reports. The weight of the evidence indicates that social determinants of health 1) have a direct impact on health of individuals and populations, 2) are the best predictors of individual and population health, 3) structure lifestyle choices, and 4) interact with each other to produce health.
Canadian policy-makers should be aware of these findings. Canada has been a world leader in developing the implications of these findings through the health promotion and population health concepts. In 1974 the federal government’s report, A New Perspective on the Health of Canadians (the Lalonde report), saw health and illness as being determined by human biology, envi- ronment, lifestyle, and health care organization. The document was important in that it identified determinants of health other than the health care system.
Another Canadian government document, Achieving Health for All: A Framework for Health Promotion (the Epp report, 1986), identified a prime goal of reducing inequities between income groups by influencing the social determinants of health when it stated that all policies with a direct bearing on health need to be co-ordi- nated. The list of policy areas is long and includes, among others, income security, employment, education, housing, business, agriculture, trans- portation, justice and technology. The 1999 Health Canada document, Taking Action on Population Health: A Position Paper For Health Promotion and Programs Branch Staff, states:
There is strong evidence indicating that factors out- side the health care system significantly affect health. These ”œdeterminants of health” include income and social status, social support networks, educa- tion, employment and working conditions, physi- cal environments, social environments, biology and genetic endowment, personal health practices and coping skills, healthy child develop- ment, health services, gender and culture.
Documents published by the Canadian Public Health Association (CPHA) tell a similar story. In 1986, its Action Statement for Health Promotion in Canada identified advocating for healthy public policies as the single best strategy to affect the determinants of health. Priority areas mentioned include reducing inequalities in income and wealth, and strengthening communities through local alliances to change unhealthy living condi- tions. In 2000, the CPHA endorsed an action plan that recognized the pro- found influence of poverty on health and identified ways to reduce its inci- dence. These developments influenced health policy thinking around the world, including recently that of the US National Policy Association and the Centres for Disease Control and Prevention.
In spite of this accumulated knowl- edge, Canadians continue to be told””with some notable exceptions”” by governments, health care providers, disease associations, public health units, and media””that lifestyle choices are both a threat to and the salvation of their health. What is not mentioned is that the evidence for this is contested and that biomedical inter- ventions and lifestyle choices are a small factor in whether individuals stay healthy or become ill. Not surprisingly, research indicates that the Canadian public has little awareness of the importance of the social determinants of health.
The reasons for governmental inaction on the social determinants of health are relatively easy to ascertain but much more difficult to redress. In the context of building healthy public policy to influence the social determi- nants of health, the Kirby report dis- cusses the difficulties of implementing policies requiring intersectoral action as well as longer time frames to assess effectiveness. Social determinants of health thinking require various min- istries to co-ordinate policy-making and implementation. Federal and provincial ministries of health appear to be the ideal venues for such co- ordination but, as Gill Walt points out in Health Policy: An Introduction to Process and Power (1994) in regards to national governments, ”œThe Ministry of Health is often described as the Cinderella among ministries. In the hierarchy it will usually come after the Ministries of finance, defence, foreign affairs, industry, planning, and educa- tion…” And in a statement that applies to both federal and provincial min- istries, she adds: ”œThe problems of pol- icy co-ordination are exacerbated by intersectoral rivalry and territorial jeal- ousy: each ministry is, in the end, arguing its own case for a slice of the government budget against each other’s sector’s claims.”
In addition to organizational issues related to governmental func- tioning, policy discussions on the importance of nonmedical and non- lifestyle determinants of health are increasingly rare. Indeed, in its sub- mission to the Romanow Commission, the Canadian Population Health Initiative (CPHI) of the Canadian Institute for Health Information com- mented that
[I]n recent years, as the costs and delivery of health care have dominated the public dialogue, there has been inadequate policy development reflecting these understandings [on determi- nants of health]. In fact, Canada has fallen behind coun- tries such as the United Kingdom and Sweden and even some juris- dictions in the United States in applying the population health knowledge base that has been largely developed in Canada.
The policy vacuum on social determinants of health exists within a broader context. The decline of the social welfare state in Canada and else- where””described by Gary Teeple in Globalization and the Decline of Social Reform (2000)””is driving neoliberal approaches to federal and provincial policy-making that fundamentally conflict with strengthening the social determinants of health.
Teeple argues that forces that led to the development of the welfare state at the end of World War II, and in the process strengthened the social deter- minants of health, were strong national identities, the need to rebuild Western economies, the strength of labour unions within national labour bound- aries, the perceived threat of socialist alternatives and a consensus for politi- cal compromise to avoid economic cycles of boom and bust. These forces led to more equitable distribution of income and wealth through social, eco- nomic and political reforms such as progressive tax structures, social pro- grams and governmental structures that mitigated conflicts between busi- ness and labour, among others.
These forces are now in decline. Since the early 1970s, a fundamental change has occurred in national and global economies. The rise of transna- tional corporations that easily shift investments across the globe serves to pressure nations into acceding to their demands for changes that reverse reforms associated with the welfare state, thereby reducing labour costs and maximizing profits.
Indeed, government policy-mak- ing in Canada seems intent on weak- ening the social determinants of health. Federal program spending as a percentage of GDP is now at 1950s lev- els, and government policies have increased income and wealth inequali- ties, created crises in housing and food security, and increased the precarious- ness of employment.
Political pressure on federal, provincial, and local governments to conform to these shifting ideological sands blends well with the persistent bias of health workers in favour of indi- vidualistic, biomedical and lifestyle approaches to health. The media also prefers easy-to-understand biomedical and lifestyle headlines. The social-deter- minants-of-health approach is lost among such ideological imperatives.
In 1991 we, as Canadians, were profoundly healthier than were our neighbours to the south. But since then, there have been profound changes in the distribution of income and other policy domains in Canada that are directly relevant to the social determinants of health. Recent health indicators are mixed with an increase in death rates from diabetes and men- tal illness among Canadians, while deaths from cardiovascular disease continue to decline.
The Romanow Commission report repeats the contested notion that the lifestyle factors of tobacco use, diet and physical inactivity””what UK soci- ologist Sarah Nettleton calls the ”œholy trinity of risks”””are the main causes of chronic disease in Canada. Only a few paragraphs are devoted to broader determinants of health. Recommendations for promoting health naively exhort governments to support Canadians in making healthy lifestyle choices.
The Romanow Commission report (unlike the Kirby report) neglects to stress the important issue of develop- ing a strategy for developing healthy public policy to strengthen various social determinants of health. Indeed, in calling for the establishment of a Canadian Health Council, the report fails to mention any role for it in co- ordinating and supporting govern- ment action to address the social determinants of health.
The Kirby report has an excellent presentation of what is known about the importance of the social determi- nants of health. It recognizes that the burden of disease would be reduced by building public policy to support health determinants. While repeating the contested notion that lifestyle issues are the leading causes of chron- ic disease in Canada””ignoring the effects of material deprivation associat- ed with living in absolute and relative poverty; psycho-social stress associated with income, food, and housing inse- curity; and adopting unhealthy behav- iours as a means of coping with such distress””the report states: ”œAs a first step, all policies and programs estab- lished by the federal government should be assessed in terms of their impact on the health status of Canadians. A follow-up report … will set out its findings and recommenda- tions on the potential for, and the implications of, healthy public policy in Canada.”
The Mazankowski report, A Framework for Reform, acknowledged the importance of a variety of social determinants of health such as income and education, but chose to emphasize Albertans making ”œhealthi- er lifestyle choices.” Not surprisingly, considering its ideological bent, the Alberta government enthusiastically endorsed the healthier lifestyle choice agenda.
Gary Teeple argues that the power- ful forces associated with eco- nomic globalization and the interna- tionalization of capital are systemati- cally dismantling the welfare state, a trend that has health consequences for the majority of the world’s people. Nevertheless, policy developments in Europe demonstrate the social deter- minants of health can be strengthened within a nation (see the description of policy directions undertaken by Sweden and Finland, below).
The CPHI submission to the Romanow Commission argued for establishing governmental mecha- nisms to promote intersectoral co- operation in support of various social determinants of health. It stated that
There is a need for intersectoral (governments working with the private and voluntary sectors) and intergovernmental mecha- nisms for collaborative action to address some of the major health issues discussed later in this brief. The United Kingdom pro- vides a useful example: a Cabinet Council includes Ministers for Health, Social Security, Treasury, Education & Employment, Home Office, Agriculture, Fisheries & Food, Trade & Industry, Environment, Transport & the Regions and International Development to address crosscutting initiatives to improve health””so-called ”˜joined-up’ government.
Through this Council the United Kingdom has developed national strategies to address major disease entities such as cancer, heart disease, injuries and mental health. But, of more importance, they have also devel- oped national strategies to elimi- nate child poverty, enhance early child development, raise the min- imum wage, increase funding for education and health services, reduce unemployment, improve housing and reduce crime in poorer neighbourhoods and address fuel poverty.
Participants in the ”œSocial Determinants of Health Across the Life-Span” conference in Toronto””as part of its Toronto Charter for a Healthy Canada””stated that
The federal government should establish a Social Determinants of Health Task Force to consider the findings and work to imple- ment the implications of the material presented at this Conference. The Task Force would operate to identify and advocate for policies to support population health by all levels of governmental operation.
The follow-up Kirby report on developing healthy public policy should call for such a mechanism.
But, is a healthy national public policy possible in Canada? The simple answer is yes. Nations such as Sweden and Finland are not as wealthy as Canada but have, for years, system- atically incorporated thinking about the social determinants of health into their national policy agendas.
The current National Swedish Health Policy contains numerous action areas to improve population health. These activities are the respon- sibility of the National Institute of Public Health. The six main strategies outlined are
Increase social capital in the Swedish society. This includes efforts to decrease social inequality, coun- teract discrimination of minority groups and promote local democ- racy.
Promote better working conditions. The most important issues are to decrease long-term negative stress, promote employees’ influence at work and achieve more flexible working hours.
Improve conditions for children and young people. Improve social sup- port for families with children. Support and strengthen health- promoting schools.
Improve the physical environment. Co-ordinate the work for sustain- able environment with the strug- gle for improved health.
Promote healthy lifestyles. Solidarity with those who are most vulnera- ble to lifestyle risks.
Provide good structural conditions for public health work at all societal lev- els. Support to and co-ordination of research and education in pub- lic health science.
In summary, the Swedish public health goals are relatively few and their structure is not very sophisticated compared with other countries.
However, there are two significant qualitative aspects of the Swedish poli- cy, which may be of interest: 1) The targets are formulated in terms of the determinants of health, and 2) very thorough work has been carried out in order to achieve consensus of and raise political support for the targets. The preliminary strategies and goals are supported by five of six political par- ties in the Swedish parliament.
In the Swedish case study included in Reducing Inequalities in Health: A European Perspective (2002), BurstroÌˆm, Diderichsen, OÌˆstlin and OÌˆstergren point out that
For many years Sweden has pur- sued equality-oriented health and social policies, active labour market policies and family-ori- ented policies that have result- ed in higher levels of workplace participation, less income inequality, lower poverty rates and smaller socioeconomic inequalities in the distribution of poverty than in most other countries.
The result, as expected, is that ”œCompared to many other countries, Sweden has low mortality rates, high life expectancy, and favourable health indicators across all socioeconomic groups.”
In Strategies for Social Protection 2010 (2001), the Finnish Ministry of Social Affairs and Health outlines pre- ventive social policy that 1) supports growth and development of children and young people, 2) prevents exclu- sion, 3) supports personal initiative and involvement among the unem- ployed, and 4) promotes basic security in housing. Population health can be promoted and social exclusion reduced by:
Improving efficiency and co-operation among primary, specialized and occupational health care organizations
Providing support for the general functional capacity of people of differing ages
Promoting lifelong learning
Promoting wellbeing at work
Increasing gender equality and social protection, which provides an incentive to work
Giving priority to preventive poli- cy, early intervention, and actions to interrupt long-term unemploy- ment
Reducing regional welfare gaps
Controlling substance abuse
Promoting active participation in international policy-making
Providing adequate income securi- ty as the key to building social cohesion
It should be noted that as early as 1986, four general targets were set for the population’s health under the Health for All program: Adding years to life, through a decline in premature deaths; adding health to life, by show- ing a decline in chronic diseases, acci- dents and other health problems; adding life to years, by promoting good health and functional capacity for longer in life, with welfare to match; and reducing health disparities between population groups, producing smaller health differences between genders, socio-economic categories and people living in different regions.
The Finnish Government Resolution on the Health 2015 Public Health Programme (2001) concluded that progress had been made on all four goals. Life expectancy for women had risen six years since the beginning of the 1970s and that for men about seven. Infant mortality continues to be well below the EU average. Mortality rates among the over 65s has also declined considerably. Incidence of heart attacks, strokes, hypertension, rheumatoid arthritis and many infectious diseases has fallen. Dental caries have decreased substantially, especially among young people. The percentage of under-55s on disability pension has also declined. Research shows that Finns in general, and especially middle-aged and older people, feel healthier on average than peers in the 1970s. Finally, mortality dif- ferences between the genders and differ- ent parts of the country have lessened.
Canadian policymakers have repeatedly stated their commitment to maintaining and improving the health of Canadians and sustaining the health care system. Supporting the social deter- minants of health is an important means of doing so. Alternative approaches to promoting healthy lifestyle choices and increasing spending on medical care are unlikely to accomplish these goals in the absence of actions focused on these broader policy issues. Policy- makers should be aware of these facts. It is time for governments to act upon these social determinants of health or else to inform Canadians as to the reasons why they are unwilling to do so.