01.07.2010 To him that has (affluence) shall be given (health)

Social determinants of health. «To him that has shall be given». This popular saying accurately sums up the principle behind the social determinants of health. People who are better off in terms of key aspects of life and work can also expect to live longer and healthier lives than others.

Pictures To him that has (affluence) shall be given (health)


How to explain the connection between inequality of life and work conditions and inequality of health? Is there a cause and effect relationship? If so, where is the cause and where the effect? Studies have shown that socio-economic factors have a determining effect on health and life expectancy. «Poverty makes you sick» is one way of putting it. Ill health can also lead to social decline, but this effect is of less significance.

The higher the social status, the better the state of health
The term «determinant» is used because our life circumstances influence or shape (= determine) our health. Despite the closeness of the terms «determinant» and «determinism», this influence does not mean that everything is preordained. An individual’s life can always take another direction, as population-based research shows. Research has also produced another finding that might initially come as a surprise – a social gradient: each rung that we climb on the social ladder improves our chances of enjoying a long and healthy life. Education, job and income are the status characteristics most frequently studied. But health is also associated with many other determinants, including material, structural, cultural and personal factors.

Inequitable distribution of negative pressures and resources
A practical model for explaining the connections between social and health-related inequality (see figure) assumes that social inequality leads to inequality of health-related pressures and resources. In figurative terms, it is as if all the negative pressures ever experienced and all the available resources consolidate themselves into a «landscape» in and around each individual. This landscape influences the individual. It has also now been demonstrated that negative pressures have different levels of influence at different phases in our lives, with certain time windows in child development in the womb and in early childhood being of particular importance. We are also now aware that negative pressures to which parents are subject can be transmitted to their children. Depending on their social background, children are lumbered with inequitable starting conditions not only in social terms but also in relation to health.

According to the model, negative pressures can directly impair health. For instance, anyone living on a busy road and exposed to polluted air can develop pulmonary disease. An extreme example is when a human being dies as a direct result of hunger. In many cases, however, determinants act indirectly, i.e. through lifestyles. But responsibility for lifestyles that have an impact on health does not rest solely with the individual. Lifestyle is substantially shaped by life’s circumstances and the prevailing social, cultural and political norms and structures.

Inequitably high thresholds for access to healthcare
Besides health-related resources and negative pressures, differences in healthcare provision also have an effect on health status. Healthcare provision - whether preventive, curative or rehabilitative – varies according to social standing. A person of low social status may have to overcome a higher threshold in order to benefit from healthcare ser­vices. This may be due to unawareness or financial factors. Quality of communication in this context is also inequitable, and in the worst of cases can result in serious misunderstandings or in cooperation problems.

Broad spectrum of research on prevention
The above model obviously cannot avoid simplification. The relationships between the units are, of course, not one-sided – reciprocal influences occur at all levels, also within fields. The significance of health determinants is associated very closely with the prevention and health promotion services prov­ided. Many different research approaches have been developed in this setting, each of them elucidating specific aspects. Take, for instance, the term «sense of coherence», which is concerned with the question of internal patterns of health maintenance. Or if we consider people’s work situation, we find another historical concept, that of «gratification crises», which occur when reward does not match effort. Perhaps we are more interested in «health literacy», which stresses people’s «maturity» in dealing with health. The list could be continued. Each approach has its own justification and makes an important contribution towards obtaining a full understanding of the factors that influence health. But the main question must be: how can the health of a population be improved?

Rich-poor divide as «social thermometer»
Let’s conclude with the provocative question as to why social conditions need to be changed at all for the less well-off to have a better chance of enjoying good health. It could be argued that the population would be better off on average if the conditions under which the more affluent lived were further improved. But this argument is mistaken. It has now been demonstrated – for Switzerland as well as for other countries – that the more inequitable the distribution of affluence, the higher the mortality rate of the population of a community. In other words, what we need to strive for is not a higher average affluence level, but affluence that is as equitable as possible.


Monika Diebold, MD, Head of the Swiss Health Observatory (Obsan), monika.diebold@bfs.admin.ch

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