BEZ’S BLOG #4Political Determinants of Health
Credit: Hawai’i Department of Health
Last month we looked at evidence that economic inequality and social spending are the critical factors in producing health in a society. These issues make health a political construct. This is not a new idea. It was voiced by the Greeks eons ago. It appears regularly since the famous statement by Rudolf Virchow over 150 years ago. Virchow, the father of modern cellular pathology, was investigating a typhus outbreak in Europe when he voiced public health’s greatest single idea. “Medicine is a social science, and politics nothing but medicine at a larger scale.” Medicine means public health, a term that came into more common use in the 20th Century.

That our health, yours and mine, depends on choices in the political arena is not common knowledge. We are constantly told to make healthy choices, whether it be the food we eat, tracking our fitbit, limiting alcohol intake, or following our doctor’s advice. Our personal health behaviours, the work we do, the incredibly expensive healthcare industry we support, and the various ways we pursue well-being matter most. Right!? Maybe not. Let’s consider the bigger political picture.

Consider from Chomsky “politics is an interaction among groups of investors who compete for control of the state.” To rephrase consider “Politics is about: Who speaks, who is being spoken to, and for what purpose.” Politics is about power, who has it and how it is used.

The phrase social determinants of health (SDOH) has come to be more commonly used by public health organizations this century. One way to try to link health production comes from what is perhaps the U.S.’s healthiest state Hawai’i. Consider a 2011 report by its Department of Health “Chronic Disease Disparities Report 2011: Social Determinants.” On page 2 is a compelling graphic (below) that conceptualizes societal health production using a metaphor common in Hawai’i. At the top, a mountain ridge with a low point, then a raging waterfall ending in a river flowing into the ocean. MAKAI (meaning by the sea) or downstream effects are the common chronic diseases that we in most industrial societies face. Heart disease, cancer, diabetes and others you all know about. We will set aside COVID-19 and represent that in a later blog. There are two banks where the river flows into the ocean. On one are presented common risk factors we recognize such as smoking, physical inactivity and obesity. The other bank is labelled Access to Health Care. The river winds downstream from the base of the waterfall. On either side of that torrent are what are classically considered SDOHs. Racism, poverty, pollution, crime, education, income and wealth. But the Hawai’i Department of Health diagram doesn’t stop there.

Above the waterfall and below the low mountain ridge are two terms strategically placed below MAUKA (Hawaiian for toward the mountains) or UPSTREAM “Root Causes.” The lower phrase is Social/Economic Conditions. Above that is the key – “Political Context & Governance.” We are led back to Virchow’s key idea.

Medicine is a social science that speaks to the factors in a society that produce health. Politics looks at the forces affecting the society at large. If the level of economic inequality produced and the way spending on people is carried out are the critical levers producing health then that relationship is established politically by the interaction among investors who compete to control the state.

Consider the healthcare industry and its investors. In the United States that business accounts for a sixth of the total economy. This powerful industry speaks very loudly to us though massive advertising sanitized as public relations. Whether it be the ubiquitous drug ads beginning with “ask your doctor about…” or full-page ads or TV spots touting a clinic or hospital, or news of great medical progress, it is impossible to escape this barrage. The investors reap incredible profits even from the ones labelled non-profit. We play into this with our choice of words. We say we access health, we pay for health, we get health; all the while it is healthcare that we access, pay for and get. The language we use represents this power nexus.

We shouldn’t rely on only a couple of sources: Virchow and Hawai’is Health Department. Geoffrey Rose was a British epidemiologist who distinguished sick individuals and sick populations. Treating sickness in an individual is going to be very different from treating a sick society. Similarly for prevention strategies. The advice a health care practitioner would give to an individual to keep healthy is not the same as what a society should do so its inhabitants are as healthy as possible. Rose’s book: The Strategy of Preventive Medicine presents these concepts. The final paragraph in this very important book is: “The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.

“Most people consider being healthy as something under individual control. Eat right, exercise, don’t drink too much or smoke and seek medical care when sick are considered important dictums to follow. Even an apple a day. While those are important, the way our society is structured matters much more. If it is done to produce health, that is if we have the right societal structure in place, then perhaps this can explain why Japan is the longest lived country despite having a much higher proportion of men smoking than in the United States. This will be covered in a future blog where we look at the role of culture in producing health—the least-well understood part of public health. Put simply: Do you ever see a lone Japanese tourist? They do things together. Do you ever see a long Canadian or American tourist?

In my decades of teaching this material, getting students to distinguish health from healthcare and to accept the limitations of personal behaviours on health production has been my biggest challenge. In May we will consider our biology from within cells to organs to individuals to populations. If we work to produce healthy populations then the constituents of that population, namely individuals, organs and cells will be healthy as a by-product. Read more at PlanetaryHealthWeeklyBlogs

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