The inequities in the conditions in which people are born, live and work are driven by inequities in power, money, and resources. Political, economic, and resource distribution decisions made outside the health sector need to consider health as an outcome across the social distribution as opposed to focus solely on increasing productivity. The scope of the scale of the influence of social determinants illustrates that social and environmental influences are highly significant, contributing to between 45% and 60% of the variation in health status. There is a need to incentivize, or require other sectors to consider health outcomes. In England, there is free universal health coverage but widespread large and persistent inequalities in health between social groups. This largely because, for many communicable and non-communicable diseases, acting at the point at which one presents with a health problem can be too late. Action on the social determinants of health is required to reduce inequities in health.
Social policy is often aligned with the social determinants of health, however, economic policies to promote growth may have done so at the expense of quality of work and security. Since 2008 austerity programs have resulted in reduced services and real cuts that affect the real value of social protection. The lower people are in the social hierarchy, the more likely they are to be obese, to be less physically active, to smoke, to suffer the consequences of alcohol. The social environment impacts on health by conditioning people’s behaviors. People under stress turn to alcohol, drugs, and violence because of that stress. It’s not very mysterious that people do that. These behaviors tend to follow the social gradient. To improve health, reduce health inequities and reduce cost on healthcare (and other service) budgets, we need to improve the conditions in which people are born, live, work and age.
From decades of research, we have learned that the determinants of health and health inequalities are most effectively addressed with upstream public policy interventions that focus on reducing poverty and income inequality, including labor market and minimum wage policies. Income is the most important ‘upstream’ determinant of health. People with lower incomes have less favorable health outcomes, higher rates of chronic disease and lower life expectancies. The differences in health outcomes that exist between socio-economic classes are referred to as health inequalities. A direct relationship exists between rising income inequalities and inequalities in health across a given population. A research report confirmed that low-income British Columbians are at greater a risk factor of chronic disease and are more likely to suffer from diabetes, heart disease, anxiety and depression than people with higher incomes. It is much more complex than just providing the poor: food, shelter and clothing.
When it comes to health, there are many factors that influence how long and how well people will live, from the quality of their education to the cleanliness of their environment. But of all social determinants of health, research shows there is one that is perhaps the most influential: income. Science consistently shows that low incomes are a significant risk factor in disease incidence and severity as well as life expectancy. One of the more obvious ways to address income inequality is by raising the minimum wage, an issue currently at the forefront of national debate and finding success in states and localities across the country. For example, a Saskatchewan study found that low-income residents’ health care costs were 35 per cent higher than middle- and higher-income groups, amounting to $179 million in annual savings to the provincial government if low-income residents had the same health care costs as middle-income residents.1
Increasing the minimum wage is a necessary step in reducing avoidable health care costs associated with poverty and inequality. By reducing health inequalities that are costly to government and have a corrosive effect on society, a $15 minimum wage and progress towards the Living Wage must be seen for what it is – a prescription for health equity and smart management of public finances. While a $15 minimum wage would bring full-time workers slightly above the poverty line, it will not fully eliminate inequalities in health outcomes for households at the bottom of the income distribution. This will require further action to boost incomes and reduce inequality through a comprehensive poverty reduction plan, improving tax fairness, increasing welfare and disability rates, upstream investments in universal early childhood education and public policies that recognize and support the role of labor unions in promoting public health.
Income security is the most important social determinant of health. Level of income shapes overall living conditions, affects psychological functioning, and influences health related behaviors such as quality of diet, extent of physical activity, tobacco use, and excessive alcohol use. Societies with greater income inequality have fewer collective resources to invest in the educational, medical, and cultural infrastructure, which in turn hurts health and stretches the social fabric. Regulatory legislation and funding can influence health across the country. For example, implementing employment laws that provide employment security, benefits during and if these jobs end, deciding whether to fund early child development programs or supports to seniors, foster care programs, or continuing education can have very different health impacts upon different segments of the population. Those whose social determinants of health needs are left to the whims of the employment market may suffer negative health consequences as a result.
Housing insecurity is a critical social determinant of health, demanding the attention of healthcare industry professionals, according to a new guidebook from the American Hospital Association (AHA). The report specifically focuses on housing as it affects various components of patient health, including liability for certain diseases, ability to access clinicians, exposure to and threat of violence, quality educational attainment, and other social factors. The 2013 American Housing Survey, a report on housing quality and access, found that about 2 percent of housing units, nearly 2 million dwellings, had severe physical problems – with a lack of plumbing, running water or heat accounting for the majority of cases – from 2005 to 2009. And the Centers for Disease Control and Prevention estimates that while lead-based paint was banned in 1978, more than 24 million homes still have deteriorated lead paint in them. More than 4 million of those are young children’s homes.
The level of educational attainment is increasingly being recognized as an important social determinant of health. While higher educational attainment can play a significant role in shaping employment opportunities, it can also increase the capacity for better decision making regarding one’s health, and provide scope for increasing social and personal resources that are vital for physical and mental health. Higher educational attainment can also play an important role in health by shaping employment opportunities, which are the major determinants of economic resources. More educated individuals will experience lower rates of unemployment, which is strongly associated with worse health and higher mortality. Higher educational attainment can also affect health by influencing social and psychological factors like greater perceived personal control, which has frequently been linked with better health and health-related behaviors, higher relative social standing and increased social support. All these factors are associated with better physical and mental health.
Healthy People 2020 organizes the social determinants of health around five key domains: (1) Economic Stability, (2) Education, (3) Health and Health Care, (4) Neighborhood and Built Environment, and (5) Social and Community Context. Economic stability includes employment, food security and housing stability. Education extends from early childhood education and development to high school graduation to enrollment in higher education. Health care includes access to public health programs and acute care system. Neighborhood and built environment addresses the availability of healthy food in neighborhood stores, quality housing that includes control of crime and environmental conditions. Social and community context encompasses social cohesion; discrimination and incarceration.2 Inequalities in the distribution of the social determinants of health are now a widely recognized problem, seen as requiring immediate and significant action. A new system would make decisions through the lens of the social determinants of health in order to counter the inequity in the system.
We need to ban making public policy decisions through the lens of the market (complex and multi-faceted issues are oversimplified allowing self-responsibility to become the dominant issues, and life-style change the response) and switch to filter social and economic policies through the lens of the social determinants of health before they are implemented to ensure they support actions that reduce inequities in the system. The problem is therefore not so much inequality typically attributed to manipulation by an economic elite, but rather the way in which the effects of inequality get distributed throughout society with certain groups comparatively sheltered from them, and others not. Once the middle class understands the effects within the community of the social determinants of health – reduction in those suffering chronic diseases, extra individuals entering the workforce, savings in welfare payments, fewer hospital admissions and fewer prescriptions for medications – they can participate in creating change when they visit the voting booth.
1 Andrew Longhurst. (05 Feb 2018) Raising the minimum wage is good for public health. https://www.policynote.ca/raising-the-minimum-wage-is-good-for-public-health/
2 Social Determinants of Health Overview. Office of Disease Prevention and Health Promotion (ODPHP 2020) https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources