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  • Think Upstream

Healthy, wealthy, and why: social determinants of health, explained

The notion that health and illness are determined by life circumstances is not new, and in recent years this idea has become a staple of health theory and teaching.

A young, wealthy looking man sits in a cafe and drinks an iced coffee, holding his cell phone.

Ryan Meili

In one of the first lectures of medical school, students are asked what they think the greatest factors are in deciding whether someone will be healthy or ill.

Lifestyle choices — like the so-called holy trinity of diet, exercise, and smoking cessation — are a common response. Others will talk about access to health services, while others reference genetics or culture. 

After this discussion, the students are shown the list of health determinants from the Canadian Institute for Health Information. In order of impact, the factors that make the biggest difference in people’s health: 

1. income status; 2. education; 3. social support networks; 4. employment and working conditions; 5. early childhood development; 6. physical environment; 7. personal health practices and coping skills; 8. biological and genetic factors; 9. health services; 10. gender; 11. culture; and 12. mass media technology (i.e., television viewing and physical inactivity).

Invariably, this list is met with a degree of surprise. As aspiring doctors, the students think they are getting into the business of making people healthy. Then they see that the services offered by the health professions barely crack the top 10 factors.

The lesson to be drawn from the list of determinants, and the one that is stressed to students, is that the most important factors that determine people’s health are social, and the most effective solutions are political.

Health services—the response to ill health—have much less effect on ultimate health outcomes than social determinants such as income and education, housing and nutrition. Gender, culture, and biology, the more immutable of the determinants, also figure near the bottom. 

What the students learn is that, while they can indeed have the power to heal, they cannot act alone. The response to illness is not limited to one profession or sector: it must be societal.

The question, then, is where does it make the most sense to focus our political efforts? In other words, which determinants of health are most directly affected by public policy?

The social determinants of health—those most directly shaped by public policy choices – are income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety net, health services, Aboriginal status, gender, race, and disability. 

As you can see, these are all areas where public policy can change a person’s situation to either improve or worsen health. When we address inadequate housing, when we stop gender discrimination and racism, when we ensure people have access to work that is safe and fair and that our children receive the care and attention they need to grow, then we can dramatically improve health outcomes. 

So what’s holding us back? 


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