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Social determination of the health-disease process: a new insertion to the lexicon

Not long ago, in an article published on the IHP website by one of its collaborators, Werner Soors, ‘A lexicon and a question’, it was asked whether it really made sense to differentiate between the social determinants of health (SDH) and the social determination of health approach. The article was based on a critical analysis of our article from 2013, “Determinación social o determinantes sociales? Diferencias conceptuales e implicaciones praxiológicas” (Social determination or social determinants? Conceptual differences and praxiological implications). For Soors, establishing a distinction is inappropriate and unnecessary as he considers the social determinants approach already sufficiently explanatory and helpful. Confounding the issue with the notion of “determination” is considered a linguistic complication of Latin American authors, in his opinion.

While this position entails an important call for reflection and self-critique, it ignores the fact that approaches and theoretical models, including the social determinants of health approach, develop and unfold in concrete settings and are not necessarily relevant in all contexts.

This is why the conceptual distinction is necessary and the clarification and discussion of apparently subtle differences in theoretical approaches even constitutes a political action – not least because it is understood that epistemological proposals imply ontological notions and have practical implications, for example, policy measures.

In the last decades, international health agendas have tended to oscillate between two main approaches: (1) narrowly defined, technology-based medical and public health interventions; and (2) approaches that understand health as a social phenomenon and propose more complex forms of intersectoral policy action, sometimes linked to a broader social justice agenda. In recent years, the latter found expression in the WHO Commission on Social Determinants of Health (CSDH) approach. The CSDH proposes a model which differentiates between two types of social determinants of health: structural determinants and intermediary determinants. Structural determinants (social determinants of health inequities) are those that generate or reinforce social stratification in the society and define individual socioeconomic position, shaping health opportunities of social groups based on their position within hierarchies of power, prestige and access to resources (economic status).

One of the limitations we identified in the SDH approach as proposed in the final report of the WHO Commission on Social Determinants of Health concerns its tendency to explore and act upon processes that produce and reinforce inequities in health, but limited to the premises of functionalist sociology, within the tenets of neoclassical economy and limited to (the) risk factor epidemiology (paradigm), that frames health problems in overly simplistic terms and hardly captures the complexity of health inequities.

While the SDH approach identifies social conditions in which people are born, live and work and claims that “social injustice is killing people on a grand scale”, the SDH approach concentrates on what society produces in terms of inequalities and reduces the scope of the critique to what is more than evident, particularly in the global South and increasingly also in the global North, failing to clarify the causes of the “causes of the causes”, that is, the processes that historically created and systematically reproduce inequities.

The social determinants of health approach is more often than not used to identify risk factors associated to the social gradient and to implement isolated interventions without addressing the “social determinants of health inequities”, tending towards “pragmatic” proposals focusing on behaviour change in individuals or rather vague measures to improve “governance”.

In this regard it should be noted that the social determinants of health approach has been used to legitimize all kinds of political measures in Latin America ranging from social democrat to the most aggressively neoliberal policy measures, which have promoted the concentration of capital on the basis of human suffering or dismantled conditions (e.g. health  systems, environment) necessary to systematically address health inequities and promote health.

Along the same lines, it should be noted that the current momentum towards Universal Health Coverage (UHC) is by no means sufficient to tackle the inequities in health and may even reinforce the patterns of exclusion, oppression and conflict that spark social inequalities and inequities in health in Latin America as this universal health insurance coverage may pool risks to avoid catastrophic health-care spending and impoverishment but does not structurally grant the right to health. In this regard, the Lancet  Editorial by Heredia et al (2014) argues that UHC schemes are usually limited to “basic packages” that translate into limited and unequal access to and use of necessary services, which due to their essentially restricted offer leads to private complementary health insurance or an additional fee reinforcing patterns of inequity. The WHO Commission on Social Determinants of Health made a clear case for universal health systems as a structural measure to address the Social Determinants of Health and yet, contradictory or not, several of the CSDH commissioners have been at the forefront of the universal health coverage (UHC) agenda (Marmot, 2013; Andrade et al., 2015) and the SDH approach has been invoked to theoretically underpin and legitimize UHC oriented health system reforms in Latin America. This contradiction may be interpreted as a pragmatic move in complex governance mechanisms or strategic linkage of agendas, yet it also seems to suggest that the SDH approach is compatible with a series of policy measures that restrict the right to health and undermine efforts structurally addressing the social determinants of health inequities. In this regard it is revealing that the structurally fragmented and systematically unequal Colombian health system is considered a UHC model.

Another limitation we have detected is that the social determinants of health approach used in Latin America does not take up nor really engages with other approaches that have emerged in the region. Consequently, it not only misses a chance to theoretically advance the comprehension of the social processes defining health inequities in the region but also remains somewhat removed from the concrete realities. The contributions of critical perspectives from social sciences, political ecology, critical geography and decolonial thinking should, for example, be considered to comprehensively address the historical and spatial health inequities in Latin America. Similarly, it is necessary to ask why the Latin American Social Medicine and Collective Health approaches around the social determination of the health-disease-care process that emerged in the 1970s are being systematically ignored – not only by European colleagues and certainly not simply as a result of language barriers.

Consequently, we advocate for the study and further development of our proposal on the social determination of health, recognizing its major contributions. Further, we recognize the need for approaches that comprehensively appraise the processes that shape our concrete social realities and rather than the result of a linear association between social factors and individual-level biology, understand the health-disease-care process as an integral part and expression of social processes in specific territories. It is in this regard that we speak of the “social determination” of the health-disease-care process, of life and of death.

In our times, this necessarily needs to translate into a systematic examination of capitalist economic and social development, moving beyond the almost mechanic recognition of “market forces” and an ambiguously defined “globalization” to display clearly the (harmful) impact of this development model on health and the environment and recognize the incompatibility of this model with healthy lives, a “healthy” planet and social equity. This probably constitutes one of the most important and fundamental differences between the Social Determinants of Health and Social Determination of Health approaches, in as far as the Social Determinants of Health approach identifies “risk factors” and tends to propose improvements within an inherently unjust system.

It is to be seen and should be further discussed whether the Social Determination of Health approach as proposed by the Latin American Social Medicine and Collective Health is just another interpretative variation of the social determinants of health, but meanwhile and while awaiting further clarification and development of the respective approaches, we do find it important to differentiate the social determinants from the notion of social determination, as a lexical possibility (this is why we claim its insertion to the lexicon), comprising an alternative epistemological proposal from the global South and certainly not simply “unnecessarily complicated vocabulary in search of a unique identity“, as Werner Soors suggests.

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