The following is an excerpt from an interview between People’s Health Radio host Aiyanas Ormond and APH organizer Martha Roberts on the social versus the structural determinants of health. Transcribed from the original interview done in the spring of 2011 on Co-op Radio.
Aiyanas: What do we need to be healthy?
Martha: I think that’s an interesting question and we ask ourselves that at the APH on a daily basis, and really my answer to that question is another question:
What do you consider health?
This is one we’ve been exploring at the APH for the past five years because really I think there are a lot of ideas out there in the community about what is health.
If you look at the definition of health as the absence of disease or infirmity, then the answer to the question of “what do you need to be healthy?” would be a functioning body without any disease or discomfort, or pain; without any physical problems. Of course, very few people actually define health this way, 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, we need to get enough sleep at night. We need to do these things in order to have a functioning body.
We tend to look at it much more broadly. If you look at the WHO definition of health, they say it’s a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. So then you get more into the nitty gritty of what is the quality of people’s lives, are they satisfied, are they happy, do they have a place to live, do they have enough to eat? We start getting into deeper questions of in our lives do we have our needs met and are we fulfilled as human beings? We tend to go this way at the Alliance for People’s Health
What do I need to be healthy? I need to have my basic needs met and I need to have something in my life that I do, or a place that I fit, where I’m welcomed and where I feel like I have fulfillment as a human being.
Aiyanas: Which brings me to the next question. 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. Can you explain what that distinction is and why you think it’s important?
Martha: Our health care system is designed on the biomedical model, which is that first definition of health, that it’s the absence of disease or infirmity. Really if you look back through the history of medicine and the development of medical sciences you’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”, not that I know what a carburetor is, but it’s an example. And so we buy a replacement part or we add some oil, or we add some kind of a chemical that makes the vehicle function better.
Well we’ve pretty much been able to say that’s too reductionist, human beings don’t function that way. So then the new fad, the new trend, is the social determinants of health. New in the last I’d say three decades, really, spearheaded by the public health movement that says people aren’t just machines, that they’re actually influenced by their environment. And so if we’re saying health is complete physical, mental and social well-being, what are those social determinants? So we say, well, if you look at people in the community, their biggest determinant, honestly, is economics; do they have money? Do they have money to access to have those things I mentioned before, the things that I need? I need a house, I need food, I need a job so I can pay my rent, I have to send my kids to school, I need childcare for when I’m working. So we say access to money and resources are the social determinants of health. We need employment, we need housing, we need food, and we need education for ourselves and for our families.
If you look at the Ottawa Charter for Health or if you look at how the Canadian Government defines social determinants of health, we’ll see these things. It also includes things like access to medical care. We need to be able to see a physician or go to emergency if we break our arm. We need these things in our lives in order to function as human beings in society.
Aiyanas: So those are the social determinants of health.
Martha: That’s the social determinants of health.
But really, you dig a little bit deeper than that and say, that still doesn’t make the cut. We have working class communities where all of their needs are met and they still lead significantly less healthy lives, by any way we counted, 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 you 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.
That leads us to a third point. So 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. And 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.
So you can give someone food at a food bank, or you can have someone actually possess enough money to go to the grocery store and go shopping and choose their own foods. And you 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, and not just nutrition, but sense of self, sense of well-being, sense of control over their lives.
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 have the things they need taken for granted.
Aiyanas: So what’s the strategy at the Alliance for People’s Health for challenging that? And especially considering that it’s more than just a health gap that’s associated with the wealth gap, but it’s actually about power and control over our communities and our society. What’s the APH approach in terms of a strategy?
Martha: I think we have two approaches.
One is that we don’t say that the social determinants of health aren’t worth looking at. We do agree, yes, there is definitely something to the social determinants of health. We start with that. We have community health projects where we say, you know what, if we need food or we need information about something, we need to know how we can get into social housing, we need to have basic health education about how to take care of ourselves and our families, where to access resources; let’s start with this. We have community health projects, where as health workers, because many of us are health workers, though some of us are community health organizers and community members passionate about health, let’s spread the knowledge around! Let’s get together as a community and ask how can we get the things that we need and how can we take care of ourselves? How can we address the question of the basic needs?
And then the second thing is to actually get involved from there in making changes. And there are two kinds of changes we want to make at the APH. There are the changes that demand more access to social services; the government needs to provide us more state services. We need to stop cutting social programs; we need to stop cutting back MSP-insured services. And simultaneously we need to start struggling as working class communities to expand social services again in the context of the expansion of budgets for business and the military. We need to say these things are unacceptable and we need to struggle for social services.
We actually need to engage people in that struggle. That for me, as an organizer, is the biggest thing we can do. If you remember back to my answer to the question, what do we need to be healthy, people need something in their lives where they feel they’re exhibiting control, and they have a meaning or a purpose. Being involved in the struggle for the health of your community through political campaigns and community health projects actually improves people’s sense of dignity, it improves their sense of self-worth, it provides them a community that’s supportive, and it improves their own sense of health and well-being.