What is health? This question is an important place to start.
If we look at the definition of health as the absence of disease or infirmity, then the answer to the question of “what do we need to be healthy?” would be a functioning body without any disease or discomfort, or pain; without any physical problems. This is called the biomedical approach. Biomedicine is medicine which focuses primarily on the use of science to develop highly advanced diagnostic and curative medical technology. Because of the high degree of medical technology developed, biomedical medicine is increasingly expensive for the public and tremendously profitable for the corporations who create these tools. While huge profits are made by these companies, often through public funds, very little overall social benefit is created by these technologies. In fact, invasive treatments in the form of pharmaceuticals, diagnostics and surgical procedures can also have very serious and harmful side-effects upon the body.
Our healthcare system is designed on the biomedical model. If we look back through the history of medicine and the development of medical sciences we’ll see that it’s really founded on this reductionist principle that if there’s something wrong in our bodies and we’re unhealthy or we have a disease that it’s a matter of fixing a tube or a pipe or a chemical process that leads to a malfunction in our body in much the same way that we’d view our car. If our car breaks down, if the tailpipe starts to smoke, if we hear a rattle, we take it to the auto mechanic; the mechanic puts it up on a lift, looks underneath, runs a few diagnostic tests, and says, “Ah ha, you need a new carburetor”. The answer is to buy a replacement part or add some kind of a chemical that makes the vehicle function better.
Most people we talk to at the APH don’t define health as narrowly as the absence of disease or infirmity, but we’re encouraged by the health messages we see to define health that way. We need to be thin, we need to eat nutritious food, and we need to get enough sleep at night in order to have a functioning body.
At the APH we define health more broadly. The World Health Organization definition of health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. And so if we’re saying health is complete physical, mental and social well-being, what are those social determinants of health? When we talk to people in the community, their biggest determinant, honestly, is economics; do they have money? Do they have money to access to have those things that they need? So we say access to money and resources are the social determinants of health. We need employment, we need housing, we need food, we need childcare, and we need education for ourselves and for our families.
What do we need to be healthy? We need to have our basic needs met and we need to have something in our lives that we do, or a place that we fit, where we’re welcomed and where we feel like we have fulfillment as human beings.
The Alliance for People’s Health makes a distinction between the social determinants of health, which is that idea of having your basic needs met, and the structural determinants of health.
What is this distinction and is it important?
Taking off from the social determinants of health, we have working class communities where all of their needs are met and they still lead significantly less healthy lives than their counterparts in upper and middle class communities. And we say, “Why is that”? So we have to dig a little bit deeper.
Then we get into the work of someone like Richard Wilkinson who says there’s a social gradient, and people are unhealthy along that social gradient. At the APH we call that class. Everyone has a social location in the economy and where that social location is, according to the role they play in society, determines whether they’re going to be healthy or not.
If we say it’s not just the social determinants of health and it’s not just your social location, then we get into what Vicente Navarro calls the structural determinants of health. That’s really the root of our analysis at the Alliance for People’s Health. It’s not just having access to those resources, but actually having control over those resources, that fundamentally makes the difference in people’s health.
We can give someone food at a food bank, or we can have someone actually possess enough money to go to the grocery store and go shopping and choose their own foods. We can guess who’s going to be healthier at the end of the day. It’s the person who has the ability, the money, the control in their lives to decide what they’re going to eat, that actually has better nutrition, a better sense of self, well-being, and control over their lives. And to take the analogy one step further, to envision a society that would truly promote healthy human beings, we need to think about how people are socially linked to the production of food – how being involved the growing, harvesting, preparation, serving and eating of food is profoundly part of being a whole, healthy human being.
At the APH we say ultimately what we need to be looking at are the structural determinants of health. That’s power in our society to make decisions, not just over your own life, but over the whole functioning of your community, and the control over the resources that you need to make the changes that need to be addressed. That’s why we see the social gradient. It’s not just happenstance that working class communities suffer less health, they suffer less health because they rely on state services and charity and have to struggle for the things that they need, whereas people in the upper classes actually live off of the labour and the lives of the working class in a parasitic process called exploitation.
This is the crux of the first point in our strategy. We’ve got to take a lesson from the experiences of the working class and oppressed and exploited communities. That’s where we’re going to find the expertise and knowledge necessary to truly achieve health for all, and where we’re going to find vibrant examples of how communities have organized themselves to build and create responsive health care systems that meet the needs of all.