In this blog, LSE students Patricia Jairos and Elizabeth Cleary share their reflections on a panel event discussing the motion, “This house believes that social determinants of health (SDH) are buzzwords in the global health field”. Studies show that SDH account for up to 55% of health outcomes, yet there exists a gap in transforming this evidence into effective policies. Reducing inequities in health requires all sectors of government as well as civil society to create tailored solutions targeting vulnerable populations.
Considering this, the LSE Department of Health Policy, in collaboration with the LSE Health Policy Engagement Committee, and the LSESU Health Society, organised a panel discussion on the 15th of March to understand how to move the conversation beyond evidence to generate impact.
The discussion was hosted by LSE students Elizabeth Cleary and Patricia Jairos. The panelists included Dr Justin Parkhurst (Associate Professor at the LSE Department of Health Policy, Chair of the LSE Global Health Initiative, and author of The Politics of Evidence), Dr Rita Issa (medical doctor, activist, and research fellow at the UCL Institute for Global Health), and Dr Eric Schneider (Associate Professor at the LSE Department of Economic History). They shared their knowledge and diverse lived experience to provide insight into the political dynamics of SDH in practice.
What are the social determinants of health?
According to the World Health Organisation (WHO), SDH are: “the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems.”
SDH can therefore be assessed in terms of a broad variety of factors.
The prominence of SDH in research has resulted in the political prioritization of these factors to improve health outcomes.
For example, the United States (US) public health initiative Healthy People 2030 has a goal specifically related to SDH: “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.”
SDH impact insight from Dr Issa
The environmental dimension of SDH is especially useful in determining health outcomes in humanitarian contexts, where vulnerable populations are often displaced and have limited access to basic services. Dr Rita Issa opened the discussion by sharing a personal account of why context is key to physical wellbeing. Dr Issa’s family is originally from Lebanon, which prompted her to return to her home country to work for Médecins Sans Frontières in the Syrian refugee response. She shared the experience of a young child she was advocating for who was severely malnourished – as was the mother. The hospitals in Lebanon had turned the child away due to their refugee status. Deprived of access to basic services, the parents were forced to resort to feeding their child contaminated water from the refugee camp. Despite Dr Issa’s best efforts, the child died. This story mirrors that of many families escaping conflict and tragically illustrates the real world implications of SDH. It also reveals the numerous entry points for action to improve health outcomes for at risk populations.
Designing people centred policies
Evaluating SDH in different contexts is no doubt critical – and challenging. In practice, profiling the key social challenges facing a group of people can lead to homogenising diverse SDH factors. The panelists highlighted why homogenising factors lead to ‘one-size-fits-all’ policies that are designed to solve experiences that are far more complex in practice. Ultimately, they fail to achieve their intended impact when individuals do not conform to the standardised targeted profile.
It is critical for individuals to be treated as individuals in the public health system as they can present unique symptoms that exist beyond the scope of care of institutions. Institutions are failing to support these individuals due to power dynamics and hierarchies within them, resulting in profound inequities. The top of the power hierarchy promotes individualist approaches to health as a political strategy to prevent the bottom from challenging political structures.
Dr Eric Schneider argued a ‘one-size-fits-all’ may not always be appropriate but there are some instances where it works. Dr Schneider referenced the US Public Health Service’s Tuskegee Syphilis Study (1932-1972), which involved 600 Black men – 399 with syphilis – whose informed consent was not given for the study. Moreover, the subjects were not offered available treatment, rendering this study unethical. Distrust in the US health system by Black people as a result of such an experiment called for collectivist policy to address institutionalised racism in the health sector.
The panelists agreed individuals should be considered holistically – both as an individual and as social groups. For Dr Issa, holistic care is an important concept. She introduced “social prescribing” – an approach adopted at her GP practice in the UK – where patients are not only provided with medical care, but assistance with housing, employment, and finances. This demonstrates a practical approach to recognising the patient as an individual and as part of a wider social system, simultaneously.
Catering to individual determinants of health involves multiple factors of complexity – often individuals sit at varying and often neglected social intersectionalities.
Effective policies require iterative evaluation and adaptation to integrate and accommodate the fluid classifications of individuals. Ignoring or misunderstanding this fluidity will continuously lead to health systems disadvantaging certain societal groups.
The political determinants of health
The panel unanimously agreed that to understand SDH, it is essential to understand the dynamic structures of power in politics, and the implications for the design and implementation of policy. Dr Issa captured this with the inquiry, “What determines the determinants of health?” Dr Parkhurst suggested that this “what” is often at the very core of political intervention: there is a line to tow between looking at the outcomes of policies but also the fundamental structures of such power imbalances.
Ultimately, the politics of SDH is murky and leads to confusion around what can be done and when.
Different actors have varying levels of authority, as well as jurisdictions in which they can operate, to address an issue. This dynamic of navigating between local and global authorities in health sector service delivery can make it hard to implement fast, effective, and efficient change on a wide scale. Therefore, the best initiatives are often those that are spearheaded within local communities to target a specific issue.
Going forward: achieving health equity
The panelists shared advice on the future of health policy design and implementation. Dr Parkhurst stressed the importance of having clear short-term goals that reflect the intentions of a policy and to what degree they aim to solve a problem. Dr Schneider echoed the need for short-term goals, while stressing the importance of them being oriented towards a long-term vision, as individuals often have a short tenure in policy implementation in practice. Dr Issa pointed to the frequent disconnect in the implementation process between policy and what is needed on the ground. She stressed how essential on the ground experience is to successful policy implementation. Ultimately, solving inequities in SDH is contingent on the incremental implementation of policies that measurably contribute to a new long-term vision.
The views expressed in this post are those of the authors and in no way reflect those of the Global Health at LSE Blog or the London School of Economics and Political Science.
Photo by Dina Debbas