(A longer version of this article originally appeared as The Socio-Economic Realities of Health on Tasc's website in December.)
While biological or genetic predispositions play an important role in determining dissimilar health prospects at the individual level, they fail to account for larger scale variations in health risks and the rapid changes in (healthy) life expectancies of differing social groups over comparatively brief periods. According to Farrell et al:
"Health is not just the outcome of genetic or biological processes but is also influenced by the social and economic conditions in which we live. These influences have become known as the 'social determinants of health'. Inequalities in social conditions give rise to unequal and unjust health outcomes for different social groups."
People who are less well off or who belong to socially excluded groups tend to fare badly in relation to these social determinants. Negative social determinants not only lead to health problems but also create problems in terms of access to services and recovery rates and result in varying levels of health risk between different socio-economic groups. Such health inequities impact upon individuals irrespective of what stage of life they are at and can also have detrimental effects on their later health prospects even if their overall quality of life and circumstances improve.
Mackenback et al estimate that health inequalities reduce average life expectancy across the EU25 by 1.84 years (a total of approximately 11.4 million life years lost per annum) and healthy life expectancy by an average of 5.14 years (or an approximate yearly loss of 33 million healthy life years). In economic terms, the costs of these inequities are equivalent to 20 per cent of health care costs and 15 per cent of social security benefits. When valued as a capital good – "an important component of the value of human beings as means of production" - the economic losses resulting from inequality related health problems were estimated at around €141 billion in 2004 or 1.4 per cent of EU25 GDP. If regarded as a consumption good – "health directly contributes to an individual's 'happiness' or 'satisfaction'" - the economic cost soared to €1,000 billion or 9.5 per cent of GDP.
Strengthening health equity – globally and within countries – means going beyond contemporary concentration on the immediate causes of disease. The Commission on the Social Determinants of Health (CSDH), which focuses on the 'causes of the causes' – the fundamental global and national structures of social hierarchy and the socially determined conditions these give rise to – declared starkly in a 2008 report that 'Social injustice is killing people on a grand scale.'
Maximising the overall level of health and well-being of the general population requires progressing beyond the mindset that improve health standards can only be improved through investment in public health service accessibility and delivery. Although public health services are of course an essential component of any health system, and indeed a social determinant themselves, there is an urgent need to take stock also of socio-economic factors that directly impact on our health prospects. In this respect, it is particularly important that those negative social-determinants which lead to health inequalities and inequities are effectively identified, diagnosed and targeted.
Similarly, health policy measures and their attendant programmes and initiatives should be co-ordinated throughout society, involving all the relevant stakeholders, so that negative social determinants creating increased health risks can be successfully tackled. In this respect, the development and implementation of inter-departmental policies and programmes from the government level down must play an essential part in eradicating structural inequality and endemic poverty - prime culprits in health inequity.
A determinants approach to health promotion requires action across the entirety of our society and economy. It is an approach which emphasises "coherent action" to minimise negative social determinants and foster positive ones for the entire population. This will be definitely meet with concerted opposition as there are many who would prefer the current - inequitable - status of resource distribution to remain as it is.
In the short run, we need to work towards ensuring that at the very least the social and economic status of all our citizens meets certain minimum standards. As the Founder President of the Candidate Institute for Research, J. Fraser Mustard, explains:
"If we want to produce health—and I deliberately use an economic term—we have to work on reducing poverty and socio-economic inequality. The levelling out of such inequality and the uneven distribution of wealth is an important factor if we want to continue to improve health and make wise economic choices in our investments."
For those of us who aspire to living in a just society, the provision of an essential public good such as universal and equitable healthcare is surely a prerequisite. However, not only is an approach to health based on tackling negative social determinants and health inequalities the ethically correct manner in which to proceed, it also makes sound economic sense.
Of course, such an approach will demand a long term outlook. While there are immediate measures that can be introduced to alleviate the impact of negative social determinants, it is in the long run that the real benefits will become evident.
Furthermore, there appears to be a distinct willingness on the part of the Irish population to invest in such policies. As the 2010 Tasc issue of 'The Solidarity Factor´ notes, an overwhelming majority (91 per cent) of the Irish population either strongly agree or agree that there is a pressing need for a redistribution of resources to address the issue of the inequality which lies at the heart of so many health problems. In contrast only 4 per cent strongly disagree with this proposition.
In the final analysis, the construction of a society based on the principles of equitable health and well-being for everyone is a question of social justice. As defined by the CSDH:
"Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death."
It is unacceptable that in a country where the number of High Net Worth Individuals has returned to positive growth - increasing by over 10 per cent in 2009 – we appear resolutely unwilling to mobilise the resources to maximise the health prospects of our fellow citizens.
(Image top via BertBeckers on Flickr)