Chapter 7 Book Notes

International Development Studies
Course Code
Anne- Emanuelle Birn

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Chapter 7: Social determinants of health and social inequalities in health.
BOX 7-1:
**Social determinants of health: social characteristics through which living takes place.
**Societal determinants of health: broader (poli, economic, social, and cultural)
structures that shape health and health patterns.
-Social inequalities (inequities): health disparities w/in & btw countries, that
systematically burden pop rendered vulnerable by underlying social stru & poli, econ, &
legal institutions.
-Health Disparities (mostly used in US) implies differences in health status without
necessarily implying the presence of injustice.
The social determinants of health: What makes the underlying determinants of health
societal as opposed to individual?
-Virtually every bout of ill health or injury can be understood in societal terms.
-Ex: Construction worker falls off building and dies.
-At a population level, patters of premature death and disability can also be
examined in societal terms.
-Societal determinants of health refer to those factors related to interactions among
people and communities, whereas societal determinants emphasize a broader
array of structural influences. Societal determinants of health framework
illustrates how political economy of health pathways operate
-The most immediate determinants of health shape exposure, susceptibility, and
resistance to death and illness at household and community levels
-At the next level are a range of determinants that manifest themselves largely in
terms of social policy and govn’t regulation. Ex: poverty levels, education, etc.
-The final level includes the underlying social, political, economic, and historical
context. Key determinants=class/social structure, distribution of wealth/power, etc
Check figure 4-2
*Individual Characteristics and Experience (Individual)
-Medical models of health largely attribute ill health to personal features and
actions. Every occurrence of disease, death, or disability includes varying degrees
of societal influence.
Life-course Trajectories
-A life-course perspective helps explain how disadvantage/advantage produced
through societal determinants of health accumulates over time in an individual
-Behavioural understanding of health largely ascribe health status to personal
practices and habits. Ex: unsafe sex, smoking, alcohol/drugs‘lifestyle approach’
-Health ‘behaviours’: known aslifestyle approach”- covers only one small
component of multiple levels of influences on health (differences in mortality b/w
working and upper class smokers).

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oCriticism: assumes that ppl are perfect decision makers w/ day to day
control over work & neighborhood conditions, indi approach removes
responsibility for change from govt, private business and other actors.
oex: hygiene, genetic factors
The Influence of Living Conditions (Community and household)
-Numerous ailments result from poor living conditions cardiovascular,
respiratory, gastrointestinal, endocrine, nutritional/metabolic disease, injuries and
violence. 18mil (1/3 of all) deaths = directly attributed to conditions of povery.
Water and sanitation
-1/6th of the world lives w/o adequate water supply
-Almost half of the world’s populations (2.6bil) lack access to even the most basic
sanitations and must resort to using fields and ditches mostly in rural areas
-Access to an in house water connection is closely associated w/ infant mortality.
-Connection between water/sanitation and health is complex. Ex: WHO says
washing hands reduces diarrheal diseases by 50%, but its not simply a matter of
habits, but rests on sufficient access to clean water (and soap)
-Women/girls/refugees particularly affected by poor water supply. They are
responsible for getting water can get injured, assaulted, and they miss school
Nutrition and food security
-Food security: availability of and access to sufficient qualities of nutritious food
-Food sovereignty: self determination in the production and consumption of foods
in terms socially, economically, and culturally consistent w/ local practices
-50% of child deaths, a result of poor nutrition/under nutrition
-Mainstream medical community leaves the structural factors of food distribution
and production unaddressed. Only addresses through clinical approaches.
-Malnutrition, today, is largely associated w/empty calories. Chemically
processed food that not only has little nutritional value, but can cause various
diseases. Ex: certain cancers, obesity, cardiovascular disease, etc.
-1/7th of the world have a severe hunger problem. Hunger and famine are caused
more by the economics of maldistribution than by food shortages
-Although tradition, culture, and household resources play an important role,
dietary patters are increasingly influenced by the industrialization of food
production. Processed food = cheaper/ calorie than fresh produce.
-1/3rd of global grocery sales are in the hands of 30 food retailers, and 90% of
worlds grain trade is controlled by just 5 companies. This affects another
determinant of health local sustainable farming practices.
Housing and human settlements
-Provides safety, stability, rest and leisure, and conditions that foster physical and
mental health

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-Overcrowding, inadequate ventilation and sanitation are a perfect environment for
diseases to spread. A flimsy structure will not provide protection from the
elements, animals, and violence. These conditions affect psychological well being
-If no plumbing, high risk of mosquito breeding.
-Most extreme housing problem is homelessness. Between 100mil to 1 bil ppl are
homeless in the world.
-Death rate of homeless ppl is 2 to 10 times higher than non-homeless
-The desperate conditions of homelessness can also lead to drug use, sex work, and
deterioration of mental health.
Neighbourhood conditions
-Affect the quality of housing, water and sanitation, food availability, and other
determinants of health. Tangible neighbourhood features: availability of
infrastructure and institutions (schools, health/social services, parks, stores, etc).
Non-tangible features: unemployment rates, crime, stress level, solidarity, etc.
-Nearly 1 bil ppl in the world live in slums
-Infectious diseases related to the poor health generated by the slum’s conditions
include TB, HIV, diarrhea, cancer, trauma, & stress related cardiovascular disease
Public health and health care services
-A range of community level public health activities are important determinants of
health (ex: food safety inspection and standards, epidemic and chronic disease
surveillance, control, and clinics)
-Provision of health care services is a key determinant of health
-The health system itself can also promote or jeopardize health, depending on how
equitably it is financed, its accessibility and quality, and the extent to which it
prioritizes preventive services and public health over curative services.
Culture and religion
-Culture shapes how ppl see the world and their place in it and gives meaning to
personal and collective experience.
-Health reflects cultural priorities and practices. Cultural beliefs influence the ways
in which health and illness are defined and understood.
-What one cultural group determines is harmful to health is unlikely to be
universally view as such by all cultures.
-Culture influences what actions may be taken to prevent or treat illness, and
which healing authorities to consult. Biomedical care may not be sought by some
immigrants. Important to integrate local healers and traditional medicinal
practices in health campaigns.
-Four main pillars of Gross National Happiness (GNH): 1) promotion of equitable
and sustainable socioeconomic development; 2) preservation and promotion of
cultural values; 3) conservation of the natural environment; 4) establishment of
good governance.
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