Social determinants of Health (SDH) universe. Part I

1. Social determinants of Health (SDH) universe.Part I Marcio Ulises Estrada Paneque. MD. PhD.* Genco Estrada Vinajera. MD.** Caridad Vinajera Torres. PhD.***

2. Authors. * Doctor in Sciences. Titular Professor. First & Second Degree specialized in Paediatric and Public Health. ** First Degree specialized in General and Integral Medicine. Resident in Neurophisiology. *** Doctor in Sciences. Titular y Consultant Professor. Philologist.

3. Objectives. • To approach the equity in health like a value that translates theory of social justice and like basic factor for the right to the health. • Recognize and identify health inequities like strategic element for the formulation of more equitable public policies. • Analyze the inter-sectoral policies and strategies arranged from the point of view of SDH. • Analyze the recommendations that emanate of the WHO’S SHD Commission and their knowledge networks.

4. Social determinants of Health (SDH) • Its study give us bases of reflection in order to diminish the inequidades in health, to impel the political transformation and to contribute to the best exercise of social justice and the human rights. • Its critical vision facilitate the diffusion and understanding of intervention keys, on the base of material already validated, political cradles in SDH approach, as well as recommendations of WHO Commission on SDH, year 2005. •

5. Social Determinants of health. • Its approach help to conform an agenda that includes the principles of the participating policies, having the fairness like principle and basic objective. • Its learning, like collective space of reflection, let that their approach isn’t a set of scientific evidences or cases, but an political-educational device to change the habitual ways to formulate, to question and to implement political in public health.

6. Thematics. • Values, approaches and perspective for the action to identify the foundations of the SDH and their potentiality to formulate policies. • Principles of social justice, fairness in health and human rights and theirs relations with actions on SDH. • Structural and intermediate mechanisms in the production of inequities in health between population groups and territories.

7. SDH. • The SDH talk about to the specific characteristics and the routes by means of which the social conditions affect the health, which they can be altered through documented actions. • These social processes and conditions are essential factors that determine limits or exert pressures, although without being necessarily determinist in the sense of a fatalistic determinism.

8. Inequality or social inequities in health. • Disparities of health in a country or between countries that are considered inadmissible, unjust, avoidable and unnecessary (noninevitable nor irremediable), that burdens populations that have been made vulnerable by the underlying social structure and the political institutions, economic and legal. • They are not synonymous of " inequalities in health" , since this last expression can be interpreted like referred any difference, and not specifically to the unjust disparities

9. Social equity in health. • Absence of unjust disparities of health between the social groups, in a same country or between different countries. • Promotion of the equity and reduction of inequities require not only of equality, but also abolition of the privileges. • Achieve social equity in health implies a reduction of the excessive load of bad health between the groups more affected by the social inequities, to diminish the social inequalities and to improve the mean levels of general health.

10. Social production of disease. • Theory that approaches economic and political determinants of health, and distribution of the disease in the society. • It studies the structural barriers for health. Focused in the economic and political institutions and too in the decisions that create, impose and perpetuate the economic and social privileges and inequalities. • Although is compatible with the ecosocial theory of disease distribution (ESTDD), it defers in that does not look for integrate biological concepts in the explanation of the health social modeling.

11. Biological expression of social inequality. • Talks about how the experiences of economic and social inequality are expressed biologically, from intrauterine life to the death, thus producing social inequalities in an broad range of aspects of the health. • It sees the poverty biological expressions and diverse types of discrimination, like based on the race, ethnic group, gender, sexuality, social class, incapacity or age. • It is not biological determinism that explain health social inequality through processes and biological characteristics to define property to subordinated or dominant groups.

12. Ecosocial theory of disease distribution (ETDD). • This theory try to integrate the social and biological reasonings in a dynamic, historical and ecological perspective to generate new ideas on the determinants of the population distribution of the disease and the social inequalities in the field of the health. • The fundamental question is: What and who is responsible for the population tendency of health, disease and well-being, in present social inequalities of health and its changes?

13. ETDD. • It considers how the population health from the social conditions is generated, tie necessarily with biological processes in all the temporo-space scales, from subcellular level to the world-wide, or from nanosecond to the millenium. • • The cumulative interactions between exposition, susceptibility and resistance, express accord their distribution factors in multiple levels (individual, districtal, regional, national, international or supranational) or in multiple dominions (home, work, school), in relation to ecological nests and in processes with multiple space and time scales.

14. ETDD. • Express knowledge in relation to institutions (government, prived & public sector), community, home and individuals, with the responsibility of the epidemiologists and scientists with respect to used or not used theories, to explain the social inequalities in the health. • Given the existence of complementary causes on different scales and levels, epidemiologic studies must specify scales and levels of analysis, and consider their benefits and limitations

15. ETDD. • Its epidemiologic explanations consider the temporal and space distribution of the disease, as much persistent and changing. • More than add " simply; biology" to the social analyses " or " social factors " to the biologic analyses, ecosocial conceptual frame is an systematic integrated approach, able to generate new hypotheses, without look for simple factors identified by other approach (Eg. biological) in terms of other (Eg. social).

16. SDH. Semantic debate. • Subject, although nonnew, provokes controversies. There is criticism about expression “social determinants” because it can imply the existence of preponderant social logic that determines the social actors action, which lose capacity to transform or to look for their identity. • Some prefer “health determinants”, when interpreting that social would exclude politics, economic, environmental, cultural, etc. Others affirm that “social” is a synthesis that includes all attributes.

17. SHD. Controversy. • Is controversial for some one the expressions “determinants of health” and “determinants of health inequities” • For some, first is equivalent to “epidemiologic risk factors” and the second have a transforming character, because it leads to understand the unjust hierarchies of social structures and reveals the true causes of health inequities. • Debate is not closed, SDH polysemy speaks about the necessity of a shared language, that favors a more articulated political action.

18. SHD. Reality • Understand health-disease process from this perspective, offers a broad politicized outlook and shows the necessity of more integrated and agreed policies (social governments, movements and NGO), to obtain major quality of life. • Poverty, schooling, nutritional insecurity, exclusion, social discrimination, quality of the house, lack of hygiene and little labor qualification constitute determinants factors of health inequality, morbidity and mortality.

19. For what treat population... and later put them in the same insalubre life conditions ?

20. Health systems (HS) and SDH. • In order to improve the population health and to foment the sanitary equity uiis necessary new strategies that consider social factors that influence in health. • It does not mean that equitable HS stops having importance. It must be clear that sometimes, HS is same part of the problem and that new strategies are essential to eliminate the inequities in health.

21. SDH. Essential questions • Where are originated the differences in health between social groups, if we looked for its tracks in its deeper roots? • What mechanisms lead to us from original causes to the present differences in the situation of observed health? • Where and how are possible interventions to reduce the inequities in health?

22. Origin of the SDH. • Not only the social aspects (stratification and social position) determines social inequities (at population level) but also operate through intermediate determinants generating inequities in health. • Socioeconomic factors (macro and micro), social value context and public policies are factors that conform social inequities.

23. Origen de los DSS. • People and social groups more down in the social scale, own twice more risk of serious disease and passing away prematurely. • Material and psychological causes contribute to these risks and their effects are extended to almost all diseases and death causes and to all social groups. • Social disadvantage can be pronounced in absolute or relative form, and tends to concentrate itself in the same social groups. Its effects in health are accumulated during all the life.

25. SDH and inequality. • There are not only inequalities between countries, but also within a same country are extreme differences. • In health, it happen throughout social stratification, including socioeconomic, political, cultural and geographic axes. • In order to describe the magnitude of this inequities, distance between the top and base of social scale is used. In all social gradient there are causes that can be avoided.

27. SDH. Influences. • SDH influence is not only demonstrated when we compare distance between top and base of the social stratification, but also when we analyze indicators of health in relation to other variables throughout all the social stratification. • Analysis would not focus attention only in situation of people who are in the poverty levels (poor between poor). Analysis of social distribution throughout all health social stratification indicates that all we are implied.

28. Go to Second part of this lecture.