All diseases have two causes, one pathological and the other political.
--Rudolph Virchow (1821-1902)
A very intriguing presentation by both Professor Ichiro Kawachi and Dr. Srinath Reddy at the first plenary of the Health Systems in Asia Conference in Singapore had us all thinking a little bit more about how we could integrate social determinants of health into out individual work. At the moment this theme resonated with me because I and others at ACCESS Health International are working with the Bill & Melinda Gates Foundation to develop a primary care model for Uttar Pradesh that is cognizant of the social determinants of health (the project is outlined in my colleague Anuradha's post). We are also comprehensively looking at coalitions with civil groups such as Education, Sanitation, and the Environment.
Social class and socioeconomic position is a powerful predictor of health and health outcomes. Most often, ‘healthcare’ is much less an issue than access to and utilization of healthcare services. Addressing health issues by de-contextualizing them from societal issues will lead to actions in vain. Most of the current focus of Universal Health Coverage is on ‘healthcare’ and ‘illnesses’ and the need for including a framework that inculcates social determinants of health is talked about more recently. This was one of the over arching topics of discussion at the conference. As Professor Kawachi, who teaches at the Harvard School of Public Health, rightly uses the metaphorical phenomenon of ‘upstream’ coined by Rudolph Virchow to describe the characteristic nature of physicians to treat the symptoms but to fail to understand the reason for the illness- to characterize most of the current developmental efforts towards improving health indicators and achieving UHC.
Firstly, what are social determinants? According to WHO, “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 need for action of health determinants arises out of the recognition that differential power levels, caste, gender etc. shape health seeking behavior and access to healthcare.
Building public and private coalitions to address social determinants to health
Dr. Srinath Reddy, President, Public Health Foundation of India talks about the Social determinants in Health framework is valuable both as an analytical tool and as a development agenda. As more and more countries are working towards UHC, it is crucial to use a more contextualized framework to address issues of healthcare. One of the foremost steps to be taken to notch up UHC efforts is to build civil society coalitions with other sectors such as education, environment, human rights, trade and so on. Dr. Srinath Reddy makes two strong recommendations that is specific to the Indian context but is largely applicable to most developing countries. One, there should be both public and private efforts to demonstrate the integration of social determinants of health to address health issues. These can be demonstrated in the form of pilot programs, which should be carefully assessed on all health, and non-health indicators that can then be scaled up. Two, a dedicated Social Determinants for Health Committee should be set up which functions both at central and state levels to actively guide more holistic developmental efforts.
The Three Cs of social conditioning
Professor Kawachi talks about the importance of early conditioning of people through education and awareness to bring about more integrated development. He talks about peoples choices as being influenced by three C’s- Conscious (either well informed or ill-informed), Conditioned (through early education and advertising) and Constrained (issues of accessibility and affordability). These three C’s must be kept in mind while addressing health issues to understand why an individual is making a particular choice of healthcare.
There are many challenges to integrating social determinants into health systems research. Many of us work in coalitions with other departments that have always functioned in silos. Conferences such as these are also very health focused and mostly attended by health professionals. Should there be some efforts to have conferences that allow for people from diverse sectors to address issues of health? It is perhaps time to move towards that.