Individualism and the Social Determinants of Health

Individualism was established as a Western value during the Enlightenment. During the 19th century there was reaction to many of the values of the enlightenment, except individualism. Romanticism appeared which supported the individual listening more intently to his conscience (emotion) rather than the (rational) demands of society. Existentialism stressed the importance of the individual, people had to create their own values, as traditional values were no longer the standard. Nietzsche claimed that individual freedom required freedom from all external restraints on one’s behavior. Herbert Spencer believed the individual had the right to do anything except interfere in another man’s rights. Individualism fueled the American dream – the hope for a better quality of life and a higher living standard than their parents had.

The rise of capitalism and individualism grew in tandem. Individualism is the belief that one’s place in the social hierarchy – their occupational class, income and wealth, and power and prestige as well as the effects of such placement such as health and disease status – comes through one’s own effort. Neo-conservatism supports dominance of markets and market model. The main tenants are (1) markets are the best and most efficient allocators of resources in production and distribution, (2) societies are composed of autonomous individuals who have the ability to control their own destiny through their own decisions (3) competition is the major market vehicle for innovation – there is no need for entitlements.

During the 20th century Ayn Rand championed the American idea of rational selfishness and individualism. By the end of the 20th century, individualism, happiness and capitalism were part of core values of Western culture. During the last 30 years of the 20th century the self-esteem movement created a population with an exaggerated sense of entitlement and self-tolerance. For this group the world is viewed from an emotional rather than a rational perspective that allows personal feelings to override the distinction between right and wrong. This ushered in narcissism that influenced decision-making and accountability. Such individuals learn to tolerate their errors and personal flaws and come accept themselves as okay. For example, individuals in the financial services industry with self-tolerance and a sense of entitlement leveraging the market, brought chaos on the world financial system.

In the 21st century liberty and self-determination, available to those who have sufficient financial resources and cultural capital, is out-of-reach for much of the population. Oxfam notes that the divide between the rich and the rest of society tends to grow – the top 1% now control 50% of the world’s wealth. The cause of poverty is still seen as somehow being in the eye of the beholder by the right – a narrative in which poverty is seen as an innate moral failure of the poor themselves has taken hold. John Kenneth Galbraith, an economist who warned of the dangers of deregulated markets and corporate greed, observed, “the modern conservative is engaged in one of man’s oldest exercise in moral philosophy, that is, the search for a superior moral justification for selfishness.”1

Individualism, a powerful philosophy and practice in North America , limits the public space for social movement activism. The challenge is not the amount of democracy rather it has to do with public policies that determine how the resources of the nation are to be distributed among the population. One policy change process (pluralist) approach sees policy development as driven primarily by the quality of ideas in the public policy arena such as those judged as beneficial and useful will be translated into policies by governing authorities. An alternative materialist approach is that policy development is driven primarily by powerful interests who assure that their concerns receive rather more attention than those not so situated.

A primary component of individualism is individual responsibility – being accountable for one’s personal choices. It leads to placing the focus of responsibility for one’s health status within the motivations and behaviors of the individual rather than health status being a result of how a society organizes its distribution of a variety of resources. It fits perfectly with a declining welfare state and also influences responses to health inequities. Individualism creates barriers to the quality of social determinants of health outcomes.

The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries. However, the biomedical model also fits neatly with the dominant contemporary political discourse of market individualism, with its culture of opportunity over entitlement and its disavowal of the distributive role of the state.2

It has been well documented over the past few decades that health is determined by more than one’s genetic makeup and access to/use of health care services. Individual and community health are determined by a vast array of external conditions and factors that involve housing, education, transportation, social networks and income, to name a few. We now know that these social determinants of health explain why life expectancy and good health improve in some communities and fail to advance in others. That is, inequities in health – or avoidable health inequalities – occur because of the ‘circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness.’

In most of the world, labour’s share of national income has fallen continuously and wages have stagnated under this regime of privatisation, deregulation and low taxes on the rich. Poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad politics. This variation among individuals and groups due to income is referred to as the “social gradient.” The social gradient illustrates that higher income levels result in better health outcomes, where lower income levels result in poorer health outcomes. Even in affluent countries such as the US and Canada the social gradient exists but is often masked by the high levels of overall population health status (Mikkonen & Raphael, 2010). The social gradient not only represents the effects of income on health but also the importance of income as a means of gaining access to other social determinants of health such as education, food, housing, recreational activities, and other societal resources.

Education plays an important role in determining health status of an individual, but is more likely to be linked to income, employment, and career success than it is to an individual having a greater store of personal knowledge. With higher levels of educational attainment, individuals have access to less hazardous jobs, and reduce their risks associated with workplace injuries. In addition, their education attainment provides more access to employment with job security, retirement plans, and health insurance that is not covered by government health programs.

Mikkonen and Raphael (2010) call attention to an issue that many people never consider: When is something a privilege or right, or a citizen right, as opposed to something that has to be purchased as a commodity? Take the example of health care. Some countries offer full coverage for all required health care including prescribed medications, dental care, and home care. Access to health care, in this example, is determined by the decisions of those in political power. But this concept also applies when we consider the important social determinants of freedom from poverty, housing, food, employment, and the ability to participate in society. In many developed nations, governments take on the responsibility of assuring access to these social determinants of health.3

The Canadian Institute for Health Information (CIHI) has shown that disparities in health associated with socio-economic status are reflected in the costs to the health care system. Preventable disease and injuries drive higher hospitalization rates for lower-income groups. In other words, there is an excess hospitalization rate for people from lower-income groups, which is likely related to preventable causes of disease and injury. High hospital admission rates among patients with low socio-economic status for the treatment of chronic illnesses that, ideally, should be managed on an outpatient basis suggest that these patients face underlying barriers to optimal primary care.

Policy options that support the social determinants of health must reduce the incidence of poverty, reduce social exclusion, and restore and enhance social infrastructure. Policies to reduce the incidence of poverty include raising the minimum wage to a living wage, improving pay equity, restoring and improving income supports for those unable to gain employment. Policies to reduce social exclusion include ensuring families have sufficient income to provide their children with the means of attaining healthy development, assure access to educational, training and employment opportunities especially for the long-term unemployed, and create housing policies that provide enough affordable housing of a reasonable standard. Policies to restore and enhance infrastructure include restoring eligibility and level of employment benefits to ensure health, as well as address the working poor that includes universal welfare policy that has been effectively combined with job creation strategies that support gender equality and accessibility.

The road map leading to less inequality includes education, motivation, and activation. There is need for education by raising public awareness of the social determinants of health. The population has been subject to continuous messaging as to the benefits of trickle down economics that benefits everyone. This messaging lacks the societal effects of reduced government and regulations – increasing income and wealth inequality, persistent poverty and increased working poor. These factors impact the health and the opportunities for many to reach their full potential. The epidemic of chronic disease appearing in the US and Canada – obesity and type II diabetes – are the health consequences of present policies.

Motivation is about shifting public, professional and policy maker’s focus. There is a need to shift from the biomedical model that Nettleson calls the “holy trinity of risk”, of tobacco, diet and physical activity. This means within the traditional health sciences approach health problems remain individualized, localized, de-socialized and de-politicized. This fits the neo-conservative political ideology whereby social problems are being continually framed as individual ones rather that societal (e.g unemployment, poverty, racism, etc,). This dominant lifestyle health paradigm needs to shift to social determinants of health perspective by collecting and presenting stories about the impact social determinants of health have on people’s lives.

The most difficult role is to develop the political will to support action to refocus agendas on the determinants of health. The quality of any number of social determinants of health within a jurisdiction is shaped by the political ideology of governing parties. The rich, via lobbyists and Byzantine tax arrangements, actively work to stop redistribution. Inequality is not inevitable, it’s engineered.4 It is about the rise of business power and the decline in labor power (as part of the era of globalization) along with the attacks of the “new right” on the welfare state – consequently there is a rapid rise in social, income and health inequalities. The philosophy of individualism provides the support within the general population that keeps this system of privilege in place. However, the social determinants of health concept can help make the links between government policy, the market, and the health and well-being of citizens to surmount the barriers to change.5

  1. Horsman, Greg. (2012) Objectivism Lost and an Age of Disillusionment. P 26, 27,147
  2. “Social Determinants of Health.” http://www.who.int/social_determinants/sdh_definition/en/
  3. Commission on Social Determinants of Health (2008). Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.
  4. Moore, Susan. (19 Jan 2015) “Inequality isn’t inevitable, it’s engineered. That’s how the 1% have taken over.” http://www.theguardian.com/commentisfree/2015/jan/19/inequality-inevitable-1-per-cent-growth
  5. Raphael, Dennis, Curry-Stevens, Ann and Toba Bryant. “Barriers to addressing the social determinants of health: Insights from the Canadian experience.” Health Policy 88(2008) p 222-235.
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