January 13, 2014
Birn “Addressing the Social Determinants of Health”
• Costa Rica vs. USA
o In 2006, Costa Rica had a life expectancy of 78 akin to the USA
o However Costa Rica’s GDP was over 5 times lower than that of the USA
o USA also spent more on healthcare than Costa Rica
• India vs. USA
o Citizens of Kerala earning less than $3000US in per year had a LE of 74.6.
o Washington citizens earning almost $30,000US per year had a LE of 72.6.
• Thus, the structure of societies comes into play.
o Things like, the role of the distribution of power and of political, economic, and
social resources in shaping population health.
o Showing factors like genetic endowment and behaviour only explain a small
fraction of health and disease and looking more at societal determinants that
shape at national and global levels
• What makes underlying determinants of health societal as opposed to individual?
o Patterns of premature death and disability can be examined at the societal level.
Ie. Neighbourhood conditions, work environment, availability of social
o A political economy of health approach considers the political, social, cultural,
and economic contexts and the way societal structures interact with particular
conditions that lead to good/bad health.
• Biomedical Model; views health and disease at the individual level, looking at the body
as a machine with parts.
• Behavioural Model; sees health and illness as a consequence for individual actions.
o While individual actions can have a bearing of health outcomes. However,
behaviours are mediated by political, cultural, economic, and other determinants
Ie. Cancer via smoking is more prevalent among the working-class
smokers than the upper-class and cessation and education are more
successful with the privileged. Ie. Congenital conditions are effected by prenatal care, which are affected
by nutrition, household services, housing, etc.
• Living conditions;
o Poor conditions can lead to cardiovascular, respiratory, gastrointestinal diseases,
o Not just housing, but neighbourhood characteristics, availability of water, social
o Homelessness is a major issue, though even those with homes may lack
necessities as per location, such as mosquito nets
o Can live in overcrowded areas that cause the spread of diseases such as asthma
and water-borne or air-borne diseases and skin ailments.
• Water and sanitation;
o Competition for scarce water creates conflict
o Lack of water spreads communicable diseases such as diarrhea
o Poorer populations pay more for water
• Nutrition and food security;
o Malnutrition kills more than AIDS, malaria, and TB
o Heavily determined by structural factors—power is in the hands of a few large
90% of world grain trade is controlled via 5 companies
o Increasing consumption of “empty calories”, ie. Junk food, even in poor nations
Caused by the mass marketing of certain food products
o Soil conditions and pesticide use are also major factors and can lead to cancers
• Public health and healthcare services;
o Such as food inspection, epidemic/chronic disease surveillance, disposal of
o 10% deaths are preventable through medical care
o Can promote or jeopardize health based on how it is financed
o Can affect what actions are taken to treat/prevent and illness o Some may treat some diseases, like fatigue-inducing anemia, as just another
part of their lives