Our Newsletter’s editor-in-chief (allow me to call you like that, Kristof) is a very curious guy. An early draft of Sara and Pierre’s Featured Article for this week’s IHP issue, ‘Health in Argentina’ had only just landed on his desk (the draft included a reference to “achievements in the field of social determinants of health”, understandable for most of us), when he asked if it wouldn’t be useful to also say a word or two on the particular Latin American concept of ‘social determination of health’, unknown to most of us. After all, one of the objectives of the IHP Newsletter’s Latin American issue is to share part of the sub-continent’s rich heritage with the rest of the world for the benefit of mankind, isn’t it?
In this comment, I offer you three things. First, a short explanation of what is meant by social determination (the lexicon part). Second, I argue that the distinction between social determination and social determinants is based on a partial understanding of social determinants. Third, I wonder whether cryptic concepts like social determination are pathognomonic for the ‘splendid isolation’ of the Latin school of social medicine (the question part).
In their 2013 article ‘Conceptual differences and praxiological implications concerning social determination or social determinants’ (Spanish with English abstract), Morales Borrero and colleagues set the concept of social determination of health apart from that of social determinants of health. In their view, the social determinants approach as adopted by the WHO is the product of “Anglo-Saxon social epidemiology” which “conceptualizes society as the sum of individuals”, “does not call into question the structural causes of health inequities arising from capitalist accumulation” and leads to a focus on individual risk factors and lifestyle. In contrast, the concept of social determination of health emerged as an “alternative to classical epidemiology” within the 20th century Latin American school of social medicine, which gives society a central place that “cannot be reduced to individual dynamics”, regards health inequities as the “product of inequitable power relations” and leads to a focus on social transformation. In their view, the social determinants approach is, at its core, based on an understanding of health and illness as dichotomic variables at individual level, whereas social determination considers health and illness as a “dialectic process” embedded in and determined by a social context.
I would argue that the distinction between social determinants and social determination is a false dichotomy in itself. The very delineation of ‘social determination’ as a separate approach is dependent on a rather restrictive interpretation of social determinants framework(s). Admittedly, Anglo-Saxon scholars have contributed a lot to the latter. True also, a mainstream framework is the rainbow model developed by Dahlgren and Whitehead, consisting of a set of concentric arcs around the individual. And indeed, the individual being in the centre of the rainbow might have made it too easy to focus on that level (only) and keep the structural determinants out of sight. Dahlgren and Whitehead themselves never did so, and neither did Marmot, Diderichsen and others in their frameworks. In fact, there is no reason to adapt such a myopic view, except stubborn neoliberalism. Morales Borrero and colleagues (no neoliberals, for sure) are simply wrong: what they call ‘social determination’ perfectly fits within a comprehensive view of social determinants. Worse, they are fighting the wrong enemy: today, when the real challenge is to reach a critical mass of policymakers who can then put our knowledge on social determinants into action, setting up a separate fraction can hardly be considered a masterstroke.
Which leads me to question a key characteristic of the Latin school of social medicine – the repetitive use of unnecessarily complicated vocabulary in search of a unique identity. Let there be no misunderstanding: I have no disagreement with the cause of social medicine and I do think we can all learn a lot from Latin America. I can also fully appreciate a good piece of Bourdieu after breakfast or one of the ‘Prison Notebooks’ from Gramsci over the weekend. But if I really want to take the cause of social medicine forward, should I then wrap up my thoughts in highbrow lingo? Iriart and colleagues, protagonists of the Latin school of social medicine, rightly note that much of the outputs of their school are hardly known in the English-speaking world. They postulate that “scepticism about research coming from the ‘Third World’” could explain lack of acceptance. Or that English itself would be the main barrier, not allowing “exact transmission, in all its complexity, of the concepts of social medicine”. As if the terms used were Spanish by origin, which is rarely the case. It does not seem to occur to them that mixing ‘praxiology’ with ‘hegemony’, or dropping a bit of Althusser dressing here and warming up some Marx basics there, does not necessarily add to understanding. Not among peers (they usually get tired – how many times have you been yawning reading this piece?), and less still among the obreros and campesinos the school pretends to represent. Which is a pity.