What is the relationship between public health and social determinants of health?

Welcome back to this Global Health YouTube channel. Today we’re going to be talking about the social determinants of health. What I’m going to do is I’m going to share with you a framework that I’ve developed for thinking about the social determinants of health. My framework is relatively simple, and the reason is this: we’re basically just going to look at two things. We’re going to say, “Look, let’s try and understand what it is that we mean by the word social, and then let’s look at the reasons that people get sick, and let’s see if we can join the dots between these two buckets.”

So let’s start by thinking about what it is that we mean by the word social. And of course we all have an intuitive sense of what the word means, but I’ve divided the word social or the idea of social into three different categories or three different buckets, and I want us to look at each of these. So the three ways that we can think about this idea of social are firstly our social environment, secondly, our social identity, and thirdly, our social position or what we sometimes call our socioeconomic position. And let’s look at each of these in a little bit more detail.

So if we start with the social environment, this is the political, economic, and cultural setting in which we live. So you might live in a country whose health policy includes providing free access to healthcare. You might live in an affluent or a deprived neighborhood. You might live in a culture that accepts and encourages gender equity or you may not, as the case may be. Now let’s talk about your social identity. Social identity is a function of the groups that you either voluntarily or involuntarily are a part of. In other words, that you identify with or that you are identified with. It could be your family, your gender, your ethnicity, your race, citizenship, the tennis club that you belong to, your language group, et cetera, et cetera. And for each of these groups, there are a set of rules that society has adopted and applied to the us, those that are a part of the group, and the them, those that are not part of the group.

So in some parts of the world, whether or not you can access education depends on your gender. In other parts of the world, you might be denied access to clean water or housing or healthcare because of your ethnicity or race. And in each of these cases, your access to certain freedoms and certain opportunities is effected by the groups or the social delineations with which you are identified.

Now let’s look at the idea of socioeconomic status or your social position. Of course, our gut feeling is that socioeconomic status is just about how much money you have. And while that’s a big part of it, it’s not the whole picture. Think for a minute about what money does for you. It’s a sort of a discretionary resource that you can exchange for whatever you can afford, and it gives you the power over resources and opportunities. In other words, it gives you options. You have a degree of what we call personal agency, but there are other things that contribute to that agency, things like education, occupation, social status, et cetera. And when we see differences in socioeconomic status across these social groups or these social delineations that we talked about earlier, we call that inequality. When that difference is because of a systematic unfairness in the rules that apply to those groups, like racial or gender discrimination, we call that inequity. So let me just summarize. Inequality is the unequal distribution of goods and opportunities and freedoms across social groups, and inequity is the unfairness that leads to inequality.

Okay, so now we’ve got a good sense of what it is that we mean by the word social. Next we’re going to take a look at the health and what are the things that cause people to be healthy or unhealthy as the case may be, and then we’re going to join these two groups up and see how they relate to each other. But before we carry on, a big thank you to USC for sponsoring this video. Here’s a quick message from USC, and then we’re going to get back into the teaching.

Dr. Shubha Kumar: Hello from Sunny California. I’m Dr. Shubha Kumar, and a professor and Director of the Master of Public Health Online Program at USC. The USC online MPH program is 100% online and delivered through state-of-the-art technology that allows students to engage with classmates and professors in live online sessions. We have a fantastic curriculum with lots of choices and taught by world-class faculty. This program can prepare you for an exciting career in public health. So if you’re interested, just click on the link below this video to learn more. We offer three start dates per year and look forward to welcoming you.

Dr. Greg Martin: So we’ve looked at the idea of social. Now we’re going to look at health, and we’re going to ask the question, why do people get sick or why do people remain healthy as the case may be? And then we’re going to look at these two ideas and see how they can connect up.

Firstly, there’s simply your biology, your age, your sex, your genes, et cetera. Next, your access to things like nutritious food, safe drinking water, clean air, shelter. Next, exposure to hazards, things like violence, conflict, war, natural disasters, infectious disease agents. Then of course there are unhealthy behaviors, things like poor diet, smoking, sedentary lifestyle. Then there’s your access to health services, and of course that includes services to treat you if you’re sick, and it includes preventative services like vaccination services and health promotion. And finally, there are psychosocial factors. So let’s take a look at each of these and ask the question, what are the social determinants that can affect them?

The first determinant of health is of course your biology, your age, your sex, your genes, et cetera. Now this is the one determinant of health that is not really affected by your social environment, your social position, your social identity, et cetera. So we’re not going to talk a lot about your biology as a determinant of health because it’s kind of quite disconnected from the social determinants except to say that some of your biology like your age or your sex can have implications for your social identity, your social position, and your social environment, as can any of the other determinants of health. In fact, even being healthy or unhealthy or disabled can impact on your social identity, your social environment, your social position, et cetera.

So I want you to see how this interaction can actually happen in both directions. Access to nutritious food, safe drinking water, clean air, shelter, people living in abject poverty, or unable to access even the most basic amenities needed to be healthy. There are about 3.1 million children that die every year due to malnutrition. Now, globally, there are more than enough resources to address the basic needs of the very poor, but we as society choose not to. We hide behind physical and social distance between them and us, and we use that to obfuscate any real moral responsibility to act.

Exposure to hazards like violence and conflict and natural disasters and infectious disease agents. Violence and conflict are the quintessential example of people applying different rules to people in the other group, the not us, the them, so much so that in times of war we not only deny those people, that group, the right to be protected from violence, but we take deliberate actions to harm them and even kill them.

Unhealthy behaviors like poor diet, smoking, and a sedentary lifestyle. Drinking a gluten free kale and radish smoothie after 45 minutes of yoga followed by the steam bath at the local gym, this might be an incredibly healthy way to live, but let’s be honest, it’s a luxury. People living in poverty or in lower socioeconomic strata are far more likely to engage in unhealthy behaviors because they need to respond to and prioritize the immediate pressures of life over the future possibility of cardiovascular disease, for example.

Next, access to health services including prevention like vaccination services and health promotion. How the state provides access to health services dramatically impacts on the health outcomes of a population, and the people who are most vulnerable are, as always, the poor. I am a huge fan of universal health coverage, and I’ve got another video on that. If you want to watch it, please do.

Your social environment and your social identity and your socioeconomic position, of course, as we’ve discussed, can affect your physical health, but all of these things can affect your mental health, your sense of who you are, your sense of wellbeing, your psychological wellbeing. They affect the way we see ourselves. They affect the pressures that we face. They affect the agency that we have to deal with problems. And of course, they affect our access to the mental health services that we might need. I find it quite problematic that in a lot of the discussion around the social determinants of health, psychosocial factors and psychological and mental health is often under-addressed or not addressed at all.

Thanks for watching. I hope you found this useful. Stay and watch another video if you’ve got the time. Subscribe to this YouTube channel if you haven’t already. Until next time, take care.

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