Lesson 2: Critiquing the Social Determinants of Health

A problem is emerging in governments’ and health authorities over-focus on the SDoH. Karatekin et al say “The framework has become more de-politicized since its publication, with the definition of social determinants shifting toward downstream and individualized factors. In the meantime, new research fields on legal, commercial and political determinants of health and health inequities have emerged; however, these have not become integrated adequately into broader social and structural determinants of health and health inequities frameworks”.

A problem arises when a shifting landscape spends time addressing outcomes that occur to individuals rather than treating at source for fear of what they might mean. This is like a doctor repeatedly caring for someone with a cough when not trying to address why the cough exists.

In a capitalist society the means of survival are your relation to money - the ability to earn money to pay for goods and services. However, not everyone can have or hold employment. Sometimes this is down to preexisting health, mental, or physiological conditions meaning that they cannot compete for employment in a market of scarcity. Other times people may not be in employment because jobs don’t exist in their area.

‘Unemployment and job insecurity’ is a social determinant of health. However both the cases presented above invite criticism as to whether this is a social problem whereby the person needs treating or the issue needs addressing at a systemic level.

If employment is the designed means of survival then there should be a system to ensure that all people can be employed. For people with different abilities and needs, there should be avenues to employment. In this case, we invite you to question whether this is a ‘social’ determinant of health or a structural societal one about its relation to economics and the needs of businesses being put first.

A similar argument can be made regarding unemployment from lack of opportunity. Can it be a social problem when the reason for the unemployment is down to the choices of private actors in their willingness to allocate resources in geographic areas that give them the best return. It is not the person or community’s fault that there is high unemployment when opportunities are not distributed accordingly. Again, is it a ‘social’ condition when it’s more related to wider societal structures and beliefs on what is more important: the allocation of capital or the right to a fair chance in creating the means of survival?

To us, when the determinant is not related to the person’s individual agency it should not be considered social.

Wikipedia’s current articulation of the word social is as “organisms, including human(s), live collectively in interacting populations. This interaction is considered social whether they are aware of it or not, and whether the exchange is voluntary or not.” The word "social" derives from the Latin word socii meaning "allies". Many believe that people cannot survive and meet their needs other than through social co-operation and association.

Being social is a means of creating something greater than the sum of our individual parts. This is often seen as a root of ‘social capital’ - the value derived from social connections and relationships, encompassing networks, norms, and trust that facilitate cooperation and collective action. It's not a tangible asset held by individuals, but rather the potential for benefits that arise from social interactions (source, source).

So when we think about the social determinants of health, it would be ideal of they were considered in relation to what we as people create that improves the commons. For example, this could be a childcare network or food collection service to help those in need.

We invite you to think about what social determinants of health should look like, ones that reflect what supports your community being healthy.