Emerging Themes in Social Determinants of Health Theory and Research.

Since 1996, we have been working to have Canadian governmental authorities implement health-promoting public policy that would improve the quality and equitable distribution of the social determinants of health, with rather little to show for our efforts. In this commentary, we identify seven emerging themes that can help explain our failures and point the way forward.

Upon publication of Richard Wilkinson's Unhealthy Societies: The Afflictions of Inequality in 1996 and Mary Shaw, Daniel Dorling, David Gordon, and George Davey Smith's The Widening Gap in 1999, it seemed to us that the compelling importance of the social determinants of health would lead to health-promoting public policy being implemented in Canada and elsewhere. The documentation in these volumes of the adverse health effects of neoliberal restructuring in the United Kingdom during the Thatcher regime would be enthusiastically received by a public health and health care community in Canada suffering from the aggressive acceptance by Canadian authorities of neoliberal approaches to governance.

Now, more than 25 years later, with little evidence of impact on Canadian public policy of any subsequent social determinants of health work, we reflect upon what might be some of the barriers to having these issues addressed. We focus our analysis on Canada, but our analysis is relevant to other liberal welfare states where progress in addressing the quality and distribution of the social determinants of health is most problematic. While health-promoting public policy is more evident in conservative and social democratic welfare states, even there the growing influence of neoliberal approaches to governance raises significant questions as to whether addressing the quality and equitable distribution of the social determinants of health through public policy action is possible under the current economic system.

In the following sections, we identify seven emerging themes related to theory and research around the social determinants of health. We do not claim these to be reflective of all work in this area, but rather to depict work we have been undertaking over the last decade. As will be indicated, we do not have much optimism that under current circumstances, public policy will be implemented in Canada to improve the quality and equitable distribution of the social determinants of health.

Theme 1: Models of Public Policy Change

Like many researchers, we were led to believe that good-quality research informed by good-quality theory would lead to public policy innovation. This adherence to the concept of pluralism implied that governmental authorities and policy makers would consider research findings and use these to inform health-promoting public policy. As a theory of policymaking, pluralism implies that all members of society, usually working through groups, have an influence on governmental decision-making. Clearly, this is not the case as the public policy playing field is skewed against the interests of most and in favor of the powerful and influential. In liberal political economies, with their emphasis on the marketplace as the primary societal institution, power and influence are held by the corporate and business sector. Producing research findings and presenting them to governmental authorities is not in itself going to lead to quality and equitably distributed social determinants of health.

A second model of policymaking, institutionalism, implies that public policy is influenced by the established structures and processes of governmental institutions. Here, the assumption is that if we can come to understand these processes, means of promoting and implementing health-promoting public policy can occur. Despite much effort in understanding the structures and processes of governing authorities in Canada and elsewhere, little progress is being made in addressing the quality and equitable distribution of the social determinants of health. Institutionalism as a model for understanding and promoting policy change has also proven to be insufficient.

This led us to consider a political economy approach to understanding public policy that makes explicit the role of power and influence. In Canada and other liberal welfare states, it is clear that the natural trajectory of public policymaking is not to improve the quality and distribution of the social determinants of health. Numerous analysis have identified the structures and processes of the liberal welfare state and how dominance by the corporate and business sector makes the implementation of health-promoting public policy unlikely. Despite the obvious relevance of a political economy approach to understanding the social determinants of health, this view continues to be marginalized.

Theme 2: The Political Economy of Health

This realization of the importance of politics and economics in determining the quality and distribution of the social determinants of health led us to consider the distinctive features of the liberal welfare state and how corporate and business sector power and influence shape the quality and distribution of the social determinants of health. Once we direct our attention to power and influence, we come to understand how difficult it is to implement health-promoting public policy. The corporate and business sector's unrelenting drive for profit-making makes the raising of minimum wages, the unionization of workplaces, and the expansion of the welfare state difficult. Their calling for low taxation on the corporate and business sector and the wealthy limits social spending. The history of Canadian public policy is limited redistribution, low social spending, and minimal management of the labor market, all features common to liberal welfare states.

All this suggests that the key determinant of the quality and distribution of the social determinants of health is the undue influence of those who benefit from the social arrangements that create health inequalities. Such recognition pulls us away from simple and naïve attempts to influence public policy through the production of research findings and understanding of governmental structures toward one of building social and political movements to challenge the dominance of the wealthy and powerful. This requires that we link our work to the social movements literature, thereby putting a different perspective on what is necessary to improve the quality and distribution of the social determinants of health.

Theme 3: Unionization and Collective Agreement Bargaining

It has always been apparent to us that unionization and working under collective agreements are important factors that contribute to the quality and equitable distribution of the social determinants of health. Together with graduate student Jessica Muller, we explored how unionization and collective agreement bargaining plays out across welfare states, within nations, and in the experiences of unionized versus nonunionized workers. Not surprisingly, we found strong and consistent positive effects on health of greater unionization rates and working under collective agreements. We continued this examination by looking at the extent to which the flagship health promotion journal, Health Promotion International, reported on the role that unionization and collective agreement bargaining play in promoting health.

Remarkably, we found a dearth of studies that considered these issues, and those that did were concentrated among a few contributors. In most cases, unions were simply mentioned as being partners in a workplace health-promotion program. In some significant instances, however, it was recognized that not only do unionization and collective agreement bargaining support the health of workers, but they also lead to public policy being influenced by a strong labor movement, leading to higher quality and more equitable distribution of the social determinants of health. We linked these findings back to the Commission on Social Determinants of Health Employment Conditions Network in the hope that it would lead to future emphasis by health promoters and other advocates on unionization and collective agreement issues.

Theme 4: Corporate Domination of the Base and Superstructure of Society

In addition to understanding how corporate and business sector power influences the distribution of income and the provision of benefits and services, it is becoming increasingly clear that corporate power and influence has seeped into all aspects of civil society such that even recognizing the role that the quality and distribution of the social determinants of health play in health outcomes has become difficult. We have considered how corporate and business power has shaped not only what Marx called the base of society—that is, the economic relations that produce, organize, and distribute resources—but also the superstructure of capitalist society. The superstructure of capitalist society includes the media, laws and policies, and educational and other institutions that come to justify the base economic relations of society through ideological messaging that makes it difficult for the public to understand these processes.

More specifically, we have documented how the corporate and business sector has come to dominate disease associations such as Heart and Stroke Canada and Diabetes Canada. Arguably, corporate and business domination of the economy produces the conditions that lead to chronic illness such as heart disease and diabetes. Their domination of the boards of directors of these organizations then leads to messaging from these organizations focused on so-called lifestyle factors, with no mention of how living and working conditions come to cause these afflictions.

In more recent work, we documented the effect of corporate domination of the boards of directors of civil society organizations concerned with reducing household food insecurity.[9,10] As with our work on disease associations, we showed how corporate and business domination of the boards of directors is associated with messaging that says little about the structural causes of food insecurity. Instead, the major food banks and food diversion organizations perpetuate the myth that food banks are an effective means of responding to food insecurity. Not surprisingly, considering the constitution of the boards of directors, there is little mention in their statements and reports of the importance of raising wages, and no mention of promoting unionization of workplaces or raising taxes on the corporate and business sector and the wealthy to improve social assistance and other benefits whose levels are so low as to drive people to visit food banks and consign them to living in poverty.

Theme 5: Neoliberalism, Redistribution, and Service Delivery

Garret identifies six dimensions of macro-level neoliberal governance: (1) overturning embedded liberalism that regulated entrepreneurial and corporate activities from the end of World War II until the mid-1970s, (2) the reconfiguration of the state to better serve the interests of capital, (3) patterns of income and wealth distribution that benefit the rich, (4) increasing insecurity and precariousness, (5) a rise in mass incarceration, and (6) a strategic pragmatism by which governing authorities are willing to stray from the tenets of neoliberalism when faced with natural or economic crises. These issues directly relate to the quality and distribution of the social determinants of health.

We observed that while attention has been given to the macro-level effects of neoliberalism on the distribution and quality of the social determinants of health such as income, housing, and food security, there has been rather less attention paid to the influence of neoliberalism on the organization and delivery of social and health services, also important social determinants of health. The adoption of business-oriented management approaches such as New Public Management has led to a decline in the quality and access to services to the most vulnerable in society. Interestingly, the best work on this has come from the Nordic nations, which, while being able to avoid the most egregious macro-level effects of neoliberalism, have seen a deterioration in the quality and access to social services as a result of increasing acceptance of neoliberal-oriented approaches to service delivery.

Theme 6: Communication and Polemic

Another emerging theme is that of communicating how imbalances in power and influence affect health. Usually, the assumption is that neutral, objective-sounding communication of research results is a means of influencing the making of public policy. The failure of this approach has led to discussions about the role of valence or intensity and its value in communicating the adverse health effects associated with poor quality and inequitable distribution of the social determinants of health.

As early as 2005, the Health Council of Canada called for use of “strong language” to describe health inequalities. Navarro stated, “It is not inequalities that kill people, it is those who are responsible for these inequalities that kill people”. We documented how growing social and health inequalities have been associated with the reemergence of Friedrich Engels’s concept of social murder by which the capitalist economic system not only sickens many prematurely, but also consigns them to premature deaths. We also showed increasing use of the concept of social murder in the mainstream news media. It is unclear at this point whether the use of polemic in communicating information about the importance of the social determinants of health can be a means of spurring action to promote health-promoting public policy. Certainly, there is evidence from the social movements literature that emotions and affect can be crucial components of successful social and political movements.

Theme 7: Social Welfare States or Socialist States

For many years, we believed that the structures and processes of social democratic and even conservative welfare states could serve as models for liberal welfare states such as Canada to emulate. Clearly, the quality and equitable distribution of the social determinants of health are superior in these welfare states compared to what is seen in liberal welfare states such as Canada. Income and other inequalities, poverty rates, and housing and food insecurity are lower. The dominant ideological inspiration of equality in social democratic welfare states and that of solidarity in conservative welfare states are clearly superior to that of liberty of the liberal welfare state. Despite these ideological differences, all forms of welfare states have been subject to the insidious effects of neoliberal governance at both the macro and service delivery levels.

In work done with graduate student Erin Flanagan on welfare states and environmental policy, we have come to question whether even eco-social welfare states will be able to avoid climate catastrophe. While the social democratic welfare states have clearly developed more proactive environmental policies than liberal welfare states, even these appear unlikely to avert the tipping point at which the Earth may become uninhabitable. An increasing eco-socialist literature suggests there is no way we can avert environmental catastrophe under capitalism. Eco-socialists harken back to Engels and Marx's belief of the incompatibility of capitalism with environmental sustainability.

The public is increasingly coming to realize that not only is a socialist state more able to deal with the environmental crisis, it is also much more likely to respond to the deteriorating quality and increasingly inequitable distribution of the social determinants of health. While eco-social welfare states are certainly an improvement over liberal welfare states, they may not be able to overcome the many barriers inherent in the capitalist economic system to improving the quality and equitable distribution of the social determinants of health.

Conclusion

Kurt Lewin stated: “If you want truly to understand something, try to change it.” Since 1996, we have been working to communicate the importance of the quality and equitable distribution of the social determinants of health in order to spur health-promoting public policy. Following Lewin, we have come to understand the numerous barriers that impede positive change. This has led us to rethink our understandings of the nature of research, the nature of societies, and the means for improving these societies. We have identified the value of a political economy approach and how it helps to understand the odious effects of corporate and business domination of our lives. We have been led to consider how alternative welfare states and even alternative economic systems can address emerging issues of the day. We are now convinced that the writings of Engels and Marx on the inherent contradictions and effects of capitalist economies are becoming increasingly relevant to understanding and responding to the continuing problems of quality and equitable distribution of the social determinants of health. The apparent inability of government authorities to control the power and influence of the corporate sector is yet another reason for a reconsideration of the current economic system and whether capitalism is capable of maintaining, much less improving, the quality and equitable distribution of the social determinants of health.