ch13_


Department
International Development Studies
Course Code
IDSB04H3
Professor
Guerra Salazar, Rene

Page:
of 10
Chapter 7: Societal Determinants of Health and Social inequalities in Health
What makes the underlying determinants of health societal as opposed to
individual?
oIll health can be understood in societal terms though people experience ill health
as individuals. Ex: construction worker falls of scaffolding and dies
§Individual: “he was inattentive and insufficiently conscious of safety” (310)
§ Household: tired from long commute to work, doesnt get enough sleep because of the
poor built of his home
§Intermediate: earns minimal salary as an undocumented worker and poor enforcement of
minimum wages
§National: poor government regulation to require his employer use quality materials for the
scaffolding and ensure safety training
§Global: emphasis on profit over worker safety or unionization to ensure social security
oSocial determinants of health – “factors related to interactions among people and
communities… social characteristic within which living takes place” (310)
oSocietal determinants of health – “structural forces… political, economic, social and
cultural structures that shape health and health patterns (310) the causes of causes
oHealth inequalities – “(a) individual health differences (b)differences in health between
population groups (c) differences between groups linked to broader social inequalities and
unequal societal structures (310)
oSocial inequalities/inequities of health – “health disparities, within and between
countries..that systematically burden populations rendered vulnerable by underlying social
structures and political, economic and legal institutions (311)
oEquity in health – “absence of systematic and potentially remediable differences in one
or more aspects of health across … populations (311)
oHealth disparities – “implies difference in health status without necessarily implying the
presence of injustice” (311)
…immediate determinants of health shape exposure susceptibility, and resistance to
death and illness at household and community levels (311) – e.g. Unhealthy behaviors
(smoking, violence, etc)
At national level determinants are brought about by “social policy and governmental
regulation” (311) that directly or indirectly affect health – e.g. social security protections,
inadequate regulation of pollution, discriminatory policies
The global level includesthe underlying social, political, economic and historical
context. Key determinants include class and social structure, distribution of wealth and power,
and international trade regimes (311).
oE.g. (+) side land redistribution and fair trade policies can improve farmer
livelihood, democractization of power can improve welfare state, economic
redistribution, environment regulation, infrastructural improvements
oE.g. (-) side trade agreements often eliminate price protections for small farmers, leading
to declines in land tenure, emphasis on production for export as oppose to consumption,
“concomitant income declines and nutritional deficiencies, all affecting health (311)
Life-course Trajectories - “explain how disadvantage (or advantage) – produced
through societal determinants of health – accumulates over time in an individual addresses
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past social conditions, the resulting influence on present-day health status, and possible
future directions of health” (312)
Health behaviors individual behaviors influenced by determinants on other levels
e.g. lung cancer morality is higher among working-class smokers than upper-class and cessation
efforts are more productive among the latter which have better means to relieve stress
Influence of living conditions term refers to “housing and neighborhood
characteristics, availability of potable water, and adequate sanitation, food quality and security”
(313) [health and social services] etc
oWater and sanitation 1/3 of the world pop. lives with moderate to severe water
stress, ½ of the world lacks access to basic sanitation. There is a correlation between
high access to an in-house water connection and low infant mortality but there are
exceptions (e.g. Iraq has high IMR and in-house water connections, high IMR could
be explained due to interruption and water contamination due to bombings, and poor
health and nutrition due to sanctions, repression and violence. Sri Lanka has a low
IMR and low in-house water connection but invests in social programs)
oNutrition and food security – food sovereignty refers to self determination in the
production and consumption of food in terms socially, economically and culturally consistent
with local practices and conditions (315). Malnutrition is often associated withempty calories
(processed foods with high sugar and fat) that contribute to obesity, CVD, cancer, etc.
§Some determinations of food (in)security: hunger (e.g. in Bengal poor
people starved despite availability of food wasting away in storehouses
because they lacked purchasing power), poor nutrition (partially due to excess
production and marketing of unhealthy food), “cornification (refers to corn-
based products in most foods) due to US corn subsidies global prices have
lowered forcing small farmers out of business in developing countries (corn
production can also cause pollution and health problems), concentration of
power in food production and trade in the hands of few corporations, which is
bad since 50% of the population of developing countries work in agriculture
oHousing and human settlementsovercrowding and inadequate ventilation and
sanitation (air and water-borne disease, TB, lice, etc), sharing beds , flimsy
construction bad during natural disasters or easier access for mosquitoes, homeless
ppl have 2-10x higher death rates
oNeighborhood conditionsaffect housing, water, sanitation quality, food availability,
access to infrastructure and institutions, note: slums have higher air and soil pollution because of
vicinity to factories and waste facilities
oPublic health and health care services include food inspection and standards, disease
surveillance, collection and disposal of refuse, road safety, sanitation and water quality
monitoring, etc
§Health system canpromote or jeopardize health depending on how
equitably it is financed…its accessibility and quality…and the extent to which
it prioritizes preventable services…over curative services (320) – e.g. Cuba
and Costa Rica have good health indicators, despite lower economic
indicators, because of emphasis on primary health care, nutritional and
educational improvements
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oCulture and religionHealth reflects cultural priorities and practices…most
people view health through cultural filters other than the biomedical lens (320) – e.g.
Jewish dietary practices are result of health concerns, Mayans view a fever as a
ailment not symptom.Cultural influences what action may be taken to prevent or
treat illness….cultural influences on health can be overemphasized” (321) – e.g.
efforts to address HIV/AIDS in sub-Saharan Africa focuses on sexual practices not
larger structural issues
oTransportroad injuries and fatalites, air quality, places for exercise and human
interaction, interpersonal security cost and…quality of urban life” (321-2). School attendance,
employment, preventive health care are effected by unaffordable transpo.
Social policies and government regulationsincludes education, health services,
taxation, union organization freedom of press, human rights and environmental protections
oIncome and poverty – some argue poverty involves more than lack of income and
should include lack of empowerment, security, social acceptance, and material
deprivation (education, sanitation, etc)
oEducationbarriers to education include user fees to attend school, distance from
schools, decrease in quality education (due to deregulation and reductions in social sector
expenditure) note: brain drain effect, civil conflict and HIV/AIDS effect of neighborhood
conditions & household environment on school attendance
oWorking conditions/employment status
§Work conditions affect health (1) “through exposures to dangerous
chemical, physical, and biological agents and the degree to which workers
are protected against them; (2) via hierarchy and worker control, workplace
stress, and the right to organize; (3)…extent of fair pay, benefits, and stability
of employment; (4) in terms of sexual, racial, and other forms of harassment
(324-5)
§Most LDC lack occupational health and safety laws
§Psychological stress can be exacerbated by work conditions (e.g. seasonal employment is
not guaranteed, lacks benefits, etc)
§…location in the production process and degree of decision making at the micro and
macro levels are key determinants of stress-related diseases…the most hazardous jobs…coal
mining, minibus driving... commercial sex work, and work involving chemicals can be more
detrimental to health than unemployment (325)
oEnvironment – problems and health consequences derive from depletion and
contamination of the earth (see pg 326)
oViolence on health LDC have 2-3x higher violent death ratesdue to high poverty
rates, political and economic inequality, rapid urbanization, competition for resources, military
conflict and repressive political regimes (326) turbulent
oSocial inclusion/exclusion, social support and social capitalexclusion results from
structural inequalities, lack of access to resources, discrimination and stigma and can lead to
premature death, increased morbidity, violence, etc. “Class structure creates social inequalities,
and reduce social capital (327) which adversely affects health.
oHuman rights and political freedomsenforcement of human rights is a key
determinant and associated with determinants related to civil, political, employment, etc
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