Social determinants or social determination of health?

The Commission on the Social Determinants of Health quite rightly turned the focus on the ‘causes of the causes’ and gave a boost to those of us in health promotion who had always called for a sociological analysis of poor health. I have been wondering recently whether the radical intent of the CSDH has been diluted - a tendency affecting any radical initiative.  The Commission was headed by Sir Michael Marmot, a medical doctor, and some have argued that the reason the report was taken so seriously was because it had the legitimacy afforded by its provenance within those medically trained. (Fran Baum, as one of the Commissioners, was the most notable health promoter. ) Following this line of thought, it could be argued – and it has been suggested by some -  that the CSDH shows continuity with the biomedical approach to disease and ill-health, showing the continued battle between the social and medical models of diseases, and the dominance of the latter in the discourse. Certainly reading various national government reports and those from the UN there is a real emphasis on the proximate causes of ill health, those related to individual lifestyles, ‘choices’ and ‘risk factors’. Mainstream epidemiology can often, perhaps unwittingly, reinforce the dominant discourse, and also, of course, the further upstream, to more distal factors, the harder it is to show the precise relationship between causes. Thus the ‘causes of the causes’ discourse has perhaps become rhetoric.

The dominance of the neo-liberal agenda and the collapse of some of promising challenges to it do not lead to great optimism for a real change to the power structures that create health inequalities. There seems to be a great disjuncture between the ideas embedded within emancipatory health promotion, with its emphasis on empowerment and people taking control of the factors determining their health, and the reality on the ground facing those experiencing health inequalities. Emancipatory health promotion has citizenship and personal agency at its heart, as it is all about individuals and communities being able to change the material circumstances in which they live. Emancipatory health promotion thinks about the social determination of health, not simply the social determinants of health. How can health be socially determined by ‘ordinary’ people, those that professionals tend to call ‘lay’ people? The social determination of health requires citizens to have a voice, power, skills and to be able to operate within the kind of state that welcomes such involvement. This is clearly not the case in so many countries today and certainly not in some of the worse cases, such as Syria, and (having just returned from Eastern Europe) not in the case of minorities such as gypsies and Roma people. Despite the focus on ‘assets’ within the health promotion discourse, many groups have neither a voice or the ability to take collective action.

Our Centre for Health Promotion Research has always followed its principles by focusing on inequalities in health, enabling ‘lay’ voices, and involving lay people as fellow researchers. My colleague Professor Jane South has recently edited a special edition the Perspectives in Public Health journal, on health trainers. The Centre for Health Promotion Research has been involved in the evaluation of health trainers since the inception of this new public health service in 2005.

The special edition carries a paper by Jane and Leeds Met colleagues Judy White and Jenny Woodward, on how health trainers can tackle health inequalities. Jane South and Dr. Shelina Vishram provide an editorial on the whole concept and evidence base for health trainers. This journal edition is unique in also including opinion pieces from a health trainer and a service user, bringing a truly bottom-up perspective to academic publications. Although the idea can appear to mimic the use of individualistic, ‘lifestyle’ trainers, the reality is that the Health trainers programme is a fascinating example of community empowerment and is a refreshing approach to tackling health in communities facing damaging social conditions.

See:

http://rsh.sagepub.com/content/133/4.toc

Health inequalities mean that people bear the scars of social conditions in their bodies and minds. ‘Embodiment’ is an outward show of power differentials, though those scars are often carried internally, in the form of depression, despair and low expectations. To be active citizens means that people have the chance to develop their own meanings of health, and also not only to respond to public health policies, but also help to create them. The health trainers programme provides one framework by which such active citizenship can be fostered. There are other examples from around the world, and they need to be heard about. Moving towards the social determination of health has to be high up in our debate within the health promotion community. Perhaps it could be the focus of the next symposium, conference, web discussion, journal edition, so that the ‘causes of the causes’ discourse does not become tamed, that the momentum of the CSDH is not lost, and that the principles, methods, and practice of socially determined health can be shared.

Health promotion, statistics, politics

As health promotion is inextricably linked with tackling inequalities in health, the role of statistics in describing inequalities is vitally important in enabling us to see those patterns of health injustice that we are so concerned to eradicate. Clearly, our work depends on having reliable data. Equally clearly, many governments and agencies have a vested interest in not providing that data, or in presenting statistics in the best light. Statistics are thus political. One of the books from my own undergraduate days was called something like ‘How to lie with statistics’ and I suspect it’s still in print. Statistics provide the bedrock of understanding,  enabling us to see what’s happening now and what direction we want to go in for the future. For example, the Radical Statistics group has as their slogan, “Using statistics to support progressive social change”  See: http://www.radstats.org.uk/journal/issue108/

It’s therefore alarming to see that the UK government is considering, as part of its cuts programme drawn up by the Office of National Statistics, to halt the publication of politically sensitive official statistics on areas such as smoking, drinking, teenage pregnancy and infant mortality. The ONS is considering cuts to the ‘wellbeing programme’ which includes data on inequalities. It’s also considering the scale of the official crime survey. At the moment, these cuts are merely being talked about, but faced with the demands for savings being made across government departments, it would not be surprising if they were enacted. It’s proposed to stop all statistics on smoking and drinking and also under threat are data on cancer survival rates, analysis of healthy life expectancy figures, and reducing the causes of death data to the legally required minimum. Many of the issues under threat are those where the UK fares badly in comparison with other European countries.

It’s only when good quality quantitative research is carried out that the scale of certain health issues can be fully outlined and explained. Thus the first comprehensive report of its kind, on violence against women, recently published by the WHO, shows comparative data from 81 countries. The director–general of the WHO, Dr. Margaret Chan commented, “These findings send a powerful message that violence against women is a global health problem of epidemic proportions. We also see that the world’s health systems can and must do more for women who experience violence”. Although we already know this, the fact that we have the data means that we have a foundation, a line in the sand, from which to advance argument and action.

The data from this work, Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence – see http://www.who.int/mediacentre/news/releases/2013/violence_against_women_20130620/en/index.html

by Dr. Claudia Garcia-Moreno and Professor Charlotte Watts, show that 45.6% of women in Africa, 40.2% in South-East Asia, 36.4% in the Eastern Mediterranean, 36.1% in the Americas, 27.9% in the Western Pacific and 27.2% in Europe will suffer physical or sexual violence at some point in their lives. That’s a third of all women worldwide – 35.6%. Of all those who experience violence, 42% sustain injuries that bring them to the attention of healthcare staff. Most of this violence comes from women’s partners/husbands – 11.9% of African women are sexually attacked by a non-intimate partner, 12.6% in wealthy countries.

The authors call for the numbers to be a wake up call. It makes the point that it’s only when numbers are collected that we can see progress in the rights of particular groups. For example, the Labour Force Survey in the UK has reported recently that more disabled people are likely to be employed today than they were ten years ago. Of course we have to be suspicious of how ‘disability’ is defined and whether there are changes in that definition, but it seems to be the case that the gap between non-disabled and disabled people in employment has shrink by 10% in the last 14 years. Universities are required to collect data on the characteristics of graduates and their ‘first destination employment’ and these show that around 40,000 ‘disabled’ people graduate each year from UK universities and of these 60% find work within six months, which is about the same proportion as their non-disabled peers.

The Radical Statistics Group’s journal is a useful source for critical discussion of why and how certain statistics are collected, and of debate about how to measure key concepts such as wellbeing.  See for example, Carr-Hill’s paper on ‘Measuring Wellbeing’:

http://www.radstats.org.uk/no107/Carr-Hill107.pdf

Another recent paper unpicks the fallacy that schizophrenia rates are constant across societies, and relates them to the political structures of various countries: 

http://www.radstats.org.uk/no107/Saunders107.pdf

Of course, statistics are a starting point and it’s then necessary for social science to make sense of those statistics and come up with explanatory frameworks. Amongst my PhD students for example, I have one looking at male sexuality in Zambia, particularly in relation to the use of microbicides to prevent HIV (with Professor Alan White, an expert in men’s health) and another looking at sexual abuse of orphans and vulnerable children in Botswana (with Professor Nick Frost, an expert in child protection).  Both will emerge with theory to explain the statistics behind the practice and attitudes that can lead to gender-based violence.

In summary, statistics and epidemiology make a key contribution to the practice of health promotion and we have to be vigilant about how such data is collected, constructed and used. Construction of statistics, what is collected and how, are political acts, just as health promotion activity to tackle inequalities, is a political act.

Paulo Freire, social action and the current protests in Brazil

Discovering the works of Paulo Freire, many years ago, was one of the turning points in my thinking as a health promoter, and he remains a huge source of inspiration to many; he quite rightly is often hailed as the most important educational thinker of the 20^th century, and we regard his works as essential reading on our courses. I am wondering what he would make of the current protests in his native Brazil, where in over eighty cities, people have been out on the streets. Direct action is one of the strategies for bringing about change that we discuss in chapter two of our book, which is concerned with how communities can take action, and of the value of ‘transformative social engagement’ (Warwick-Booth et al 2012). Our book was written at the time of the pouring out on to the streets of people all over the Middle East and of the Occupy movements. Given the strength of global capitalism, these movements might only be seen like a small fly landing on the skin of a rhinoceros and causing no more than a minor irritation, but the protests in Brazil have rattled the Brazilian President, who has been on television trying to placate the protesters. Action so far has been peaceful, which indicates that Brazilians have some faith that the democratic process is still intact.

As Freire said, if the structures don’t allow dialogue, the structures must be changed. Politicians usually recognize this, and develop means of placating the people who could topple them. Freire’s mission was to give people with no means of protest, with no voice at all, some access to that democratic process. As Martin Luther King once said, “A riot is at bottom the language of the unheard.” While people still feel there is a possibility of being heard, they protest peacefully – otherwise they riot. And people in Brazil feel there is a lot they want to say, even though many have been reported as saying that they feel they do not have a voice anymore. 

Brazil is often cited as a deeply unequal society, and indeed, using a simple Gini coefficient, it’s ranked as the 11^th most unequal society in the world – in other words there are only ten countries that are more unequal. It comes second last in a ranking of educational inequality where 40 countries are compared. 25% of students fail to progress beyond primary level. Despite Brazil’s rise as a global economy, part of the ‘BRIC’ countries, and supposedly in the top ten major world powers, the poor remain very poor. The new-found wealth has not improved public health for the poorest.  A report published by CEBRAP (the Brazilian Centre for Analysis and Planning) in 2012 talks about ‘pre-citizens’ who have no access to decent incomes, no rights and no access to good social policies. The ‘culture of silence’ that Freire was attempting to dismantle appears to remain intact.

Freire was writing at a time in Brazil’s history where a dictatorship was in charge. Dictatorships are notoriously bad for equality; one effect of the dictatorship however, was at least to enable Freire’s ideas to be more widely disseminated, as he was forced to leave Brazil. There are now eight Freire Institutes around the world, including one at the University of Central England in Burnley, Lancashire. Although Freire’s most famous work is Pedagogy of the Oppressed, the work that made a huge impact on me is his essay, ‘Extension or Communication’ which explored the practice of ‘extension’ work, where so called experts go out into rural and poor communities to give advice and ‘help’. Freire’s point in this book was that the traditional way of doing ‘extension’ work was all about a one way flow of information and he provides an alternative that informs much of the way that health promoters should, and do, work with communities today. This work is still relevant and much used, for example recently, in relation to the Framework Convention on Tobacco Control. See an interesting paper by Troian and Eichler (no date) on tobacco control in Brazil.

Whether, by coming out on to the streets,  Brazilians will effect change in the spending priorities of the Brazilian government remains to be seen in the coming weeks and months. The protests are remarkable in that Brazil is seen as the land of football yet the protests cohere around the amount of money being poured into the next World Cup. It’s being predicted as the most expensive ever staged (costing about £8 billion) and has brought people to question the wasting of public money and the corruption seen to be part and parcel of the government and ruling elites. Of course, the world economy has changed since Brazil was awarded the World Cup but even so, there appears to be a privileging of high finance over the social and welfare needs of the general population.

What does seem apparent is that taking to the streets has become a way for groups to take action and that people all over the world have found new means of telling governments that the state is part of the problem, and that they will not put up with governments doing things which are antithetical to their health and wellbeing. Paul Mason’s book, Why it’s still kicking off everywhere, suggests that these kinds of protests will be a feature of political life for years to come.

Indeed, the Congress of South African Trade Unions and the South African Communist Party have called on people to take to the streets in South Africa this week to protest about President Barack Obama’s visit to their country. There’s an undercurrent in South Africa at present, that the opportunity to create a new kind of society, post-apartheid, was lost and that the ANC sold out to the forces of global capitalism, led by America. Many South Africans do not feel that their health, education, housing and work opportunities have been improved since that day when apartheid fell. Again, Freire has a useful comment on how those who brought about revolution can become the next generation of ‘fat cats’ who have a vested interest in not bringing about change for the masses. He notes that dehumanization of the oppressed:

“ …is a distortion of being more fully human, [and] sooner or later being less human leads the oppressed to struggle against those who made them so. In order for this struggle to have meaning, the oppressed must not, in seeking to regain their humanity, become in turn oppressors of the oppressors, but rather restorers of the humanity of both.”

This is a sobering thought especially when the chief architect and symbolic father of the post-apartheid era seems to be entering the end stages of his long life.

References

CEBRAP (2012) The real Brazil: the inequality behind the statistics, available from: http://www.christianaid.org.uk/images/real-brazil-full-report.pdf

Paul Mason (2013) Why it’s still kicking off everywhere. Verso Books

Troian, A. and Eichler, M. (no date) Extension or communication? – The perceptions of southern Brazilian tobacco farmers and rural agents about rural extension and Framework Convention on Tobacco Control. Available from: http://www.jceps.com/PDFs/10-1-21.pdf

Warwick-Booth, L., Foster, S. and White, J. (2012) Healthy Communities, in Dixey, R. (2012) Health Promotion: Global Principles and Practice, chapter 2. CABI.

Austerity and Asparagus

I live in the countryside and the local farm is now selling the new season’s asparagus. I’ve a lot of friends to say thank you to so I bought six boxes at £5 each, much cheaper than in the shops, but coming to £30.  This week’s Guardian newspaper has a whole section of its Cook! Magazine devoted to this wonderful though expensive vegetable. Today’s Guardian carries a feature on a new report from a number of charities including Oxfam, and Church Action on Poverty suggesting that half a million people in the UK are now “forced to live on food banks for sustenance”. The report, 'Walking the Breadline’ links the UK government’s swingeing cuts to the benefits system, unemployment, low and falling incomes and rising food prices. The chief executive of Oxfam is reported as saying that the cuts have gone too far, “leading to destitution, hardship and hunger on a large scale. It is unacceptable that this is happening in the seventh wealthiest nation on the planet’. Indeed.

These kinds of inequalities, where I can afford asparagus but where £30 is what many families might have to feed themselves for a week, were pointed out by Wilkinson and Pickett’s ‘Spirit Level’ and also by the Commission on the Social Determinants of Health. The evidence in both is carefully constructed but one could say ‘it’s hardly rocket science’ to suggest that where people do not have the basics, their health will suffer. Another publication just out (on May 21^st) brings the political and epidemiological analysis up to date and considers the effects of the austerity measures promulgated by some western democracies on public health. David Stuckler and Sanjay Basu in ‘The Body Economic: Why Austerity Kills’ argues that there is a cause and effect relationship between austerity measures and public health declines, and that it is not recession per se but austerity measures that are causing these declines in public health and wellbeing. The key is how governments manage recession, so that a recession could be as equally bad in two countries but the effects are better mitigated by some governments than others.

They give the example of Iceland which suffered a catastrophic banking failure, and its total debt went up to 800% of GDP, far worse than debt faced by any European country today. But rather than make austerity cuts, more money was pumped into health care, diets improved through better use of local resources, investment was made in jobs and people were protected from homelessness. There has been no rise in depression or suicide and moreover, GDP growth exceeds 4% (higher than other European countries suffering recession), and unemployment is below 4%. In 2011 Iceland ranked the happiest in the world.

This is in contrast to Greece, where health care funding has been cut by 40%. Suicide rates have increased by 60%, charity helplines say they are facing unprecedented demand and rates of depression have gone up dramatically. Greece is used as the most devastating example of the mismanagement of recession, with HIV rates going up by 200%, infant mortality reportedly rising by 40%, and even malaria returning. Ireland too, has seen huge rises in suicide rates, and health care is being cut. Stuckler and Basu describe the false economy of austerity measures and how many of the actions required are counterintuitive. You could say to follow an alternative path to austerity requires more imagination than many politicians can muster, and there appears to be an appalling lack of health promotion thinking in terms of acting to prevent the inevitable public health problems that follow increased inequality and the concomitant failure to provide the basic determinants of health.

The historical approach of the book enables us to see that for example, where Sweden and Finland endured huge financial crashed in the early 1990s, their social safety nets were preserved, leading to no increases in mental health problems or other public health disasters. All in all, the analysis leads Stuckler and Basu to argue against austerity measures and for stimulus measures. The decision taken by the Icelandic people in a referendum, to reject the austerity measures suggested by the IMF, has been vindicated. There are thus robust examples of where stimulus measures have been shown to work, not only in restoring the health of economies, but also in not damaging the health of people. There need not be a tension between fiscal health and public wellbeing.

An article in the New York Times by the book’s two authors sets out aspects of their argument: http://www.nytimes.com/2013/05/13/opinion/how-austerity-kills.html?pagewanted=all&_r=0

No doubt the book requires careful scrutiny to assess the strengths of the arguments, and I am not well enough versed in health economics to do so without a more in-depth consideration. But the book makes ‘common sense’ to me and certainly other reports, such as that mentioned in the first paragraph of this blog post, would support the need for stimulus measures and highlight the shortsightedness of austerity measures. Another report just out from the International Labour Organization, Global Employment Trends for Young People 2013, shows that for 15-24 year olds, unemployment has reached 13%; this masks the true level of unemployment as so many young people are doing jobs for which they are over-qualified or where there is a skills mismatch. Global youth unemployment is reaching a ‘crisis peak’ such that many young people have given up hope of finding any meaningful work. That societies are not using the valuable talents and skills of young people is a personal tragedy as well as a huge loss to those economies. Being meaningfully occupied is a vital dimension of health; work is not the ‘be all and end all’, but it is a vital source of self-esteem, identity and self worth. Moreover of course, it provides other vital social determinants of health based on income and the ability to buy basic services, social support, companionship and hope for the future.  Lack of employment at young ages does not bode well for creating happy young people who have an investment in the societies of which they are a part. These last months have seen the death of Margaret Thatcher who came into power when one in seven children in the UK were living in poverty. When she left power, one in three children were living in poverty. These kinds of inequality have not improved since, alongside it being the norm for many never to find work. I cannot believe that the austerity measures of the current coalition government are doing anything other than storing up more future inequality and more public health consequences for many, if not most, of those in the bottom half of the income range. Meanwhile those like me, in good jobs, eat asparagus.