On the broad social conditions that are important influences on health.
IN March 2005, in what can be construed as a significant departure from established notions of viewing health issues, the World Health Organisation (WHO) set up the Commission on Social Determinants of Health (SDH). A couple of historians were asked to help the commission with its work, using their latest findings in their respective areas of expertise.
The objective behind the setting up of the commission was to bring together scientists and medical practitioners to provide evidence on policies that improve health by addressing the social conditions in which people live and work and to employ current knowledge to influence policy change and action in matters of health. The same year, the WHO also set up the Global Health Histories initiative.
The outcome of this exercise was a set of 15 papers written by historians of medicine and health. The papers were commissioned from Australasia, Africa and Asia and presented at a conference in September 2006. Harold J. Cook, Sanjoy Bhattacharya and Anne Hardy, who organised the conference, have edited the papers that constitute the book History of the Social Determinants of Health. Some of the papers make broad generalisations while others look at how health-related issues and policies have evolved over time.
Although the editors underscore the fact that the attempt to delineate and analyse the effects of the SDH helps policymakers and scholars avoid the economic determinism that has marked existing work, there is a fair degree of economic determinism as a tool of understanding in some of the papers, which, in fact, adds a richness of understanding and contextualises the problem. If there is a perceived problem with using economic determinism (the primacy of the economic structure in the development of human history) as a tool of study, it is equally problematic to understand why things are the way they are, making use of social determinants and social constructs such as race, ethnicity, social class, gender, education, government, sanitary infrastructure and access to preventive and curative medicine. But most of the commissioned papers go beyond the social, which gives the volume an intellectually honest edge.
Paul Greenough, in his paper, Asian Intra-Household Survival Logics: The Shen Te and Shui Ta options, has looked at applying the SDH approach to the Asian context. He says that barring the imaginations of the Orientalists, it hardly represents a unity in character. He seems to argue that households in Asia make vital decisions for the family members in the absence of opportunities that connect to long-term household ambitions. He says poorer families adopt desperate acts as they are chronically in need. This is more so as the state, the market and transnational development agencies are not constant partners and hence have failed to deliver the income and services needed by households.
HARSH DECISIONSShen Te and Shui Ta, mentioned in the title of the paper, are the two names of one person from Bertolt Brecht's play The Good Woman of Szechwan in which the woman, a good-hearted but impoverished sex worker, takes on the character of a man in order to survive in a cruel world. The paper argues that Asian households are constantly strategising and are capable of harsh decisions about survival when pushed into a corner and are careful to keep their sometimes brutal fertility regulating practices below the state's radar and away from the notice of the press. He seems to indicate that the households that take harsh decisions are those that have not benefitted from the wealth-generating opportunities created by the new economies of the cities in India and China. But one can have a healthy disagreement with the author on the grounds that taking extreme and difficult decisions is not merely an Asian phenomenon or a cultural response to a crisis it can apply to any community in any part of the world.
DISCREPANT SEX RATIOSThe author mentions the hugely discrepant sex ratios in certain provinces of India and China as a testimony to life-worlds filled with cruelty and despair. And the irony is that at least in India, there is sufficient evidence to show that it is not the poor households that resort to blatant sex selection but the better-off ones who have some access to the opportunities offered by the neoliberal economic policies.
The sex ratios are more favourable among the poorer sections of the population and social groups that are on the margins. The cultural response, if any, at times seems to be an outcome of the harsh economic choices that people have to make. Cultural biases sometimes take very grotesque forms in the face of harsh economic choices.
Greenough argues that while there may be commonalities across whole populations, from the SDH point of view, connecting the social determinants of health to Asian history is an awkward task. The commonalities are difficult to arrive at as intra-household resource distribution, on the basis of a two-pronged economic and social logic, influences health outcomes. These are, according to him, below the level of official surveillance and are relatively underexplored. What Greenough seems to say is that there is an inherent cultural logic that seems to be operating in addition to SDH, an argument that the following paper in the volume rebuts effectively.
Whether the cultural is the social or vice versa is a matter of academic polemic. Are there then universal social determinants of health or are they culturespecific? Are there cultural determinants as well? These are some of the questions that the papers attempt to understand.
HEALTH AMONG AFRICANSRandall Packard, in his paper on understanding the social determinants in the context of Africa, writes about the dominant understanding in countries that were colonised and in a sense carried forward this understanding in the post-colonial era as well.
Packard does not give a cultural explanation to the determinants of health among Africans but correctly tries to connect the colonial understanding, the criticism of it, as well as the resurrection of several issues around the stereotypical understanding of the determinants of health that were hitherto considered part of the colonial legacy, and which have resurfaced.
Packard is critical of British social anthropologists such as E.E. Evans Pritchard, A.R. Radcliffe Brown and even Bronislaw Malinowski, who worked during the inter-War years. Their understanding broadly was that African societies were bounded, ordered and shaped by cultural traditions that were immune to the forces of social change. The impact of colonial social and economic policies on African health became a subject of interest in the 1920s and 1930s.
Interestingly, Packard writes that a major focus of these inquiries was nutrition. His paper includes several significant references, including a citation from an article by Michael Worboys on The Discovery of Colonial Malnutrition between the Wars (in Imperial Medicine and Indigenous Societies, ed. David Arnold; Manchester University Press, 1988) where the draft report of the British Economic Advisory Committee on Nutrition in the Colonial Empire in 1938 identified poverty and secondarily ignorance as the main causes of malnutrition. The report's criticism of British colonial policies, which were quoted by Packard, was toned down in the final committee report, which emphasised the need for technical solutions such as dietary supplements. Other prejudices also reigned. For instance, many early medical observers felt that African ill-health was a product of an incomplete adjustment to civilisation.
This view supported the dominant political and economic interests and remained unchallenged until the advent of the later generation of physicians and anthropologists influenced by Marxism who argued that it was the broader forces of colonialism and industrialisation that were the critical determinants of African health. It was society, they summed up, that was pathological.
Packard says that because of the fractured nature of the colonial understanding of the social determinants of health, researchers were prevented from viewing the rather complete range of forces operating in Africa and from linking local cultural patterns with broader political and economic forces.
The thinking changed in the 1940s when a group of progressive physicians working in South Africa linked disease with migration. They argued that the behaviours that placed Africans at risk were a product not of ignorance or maladjustment but of the conditions under which they were forced to live. Issues of fertility and large family size were interpreted as the inability of the African to adjust to civilisation and industrialisation.
Packard says it mirrored earlier explanations of African ill-health. He argues, very rightly, that there is a gap between our understanding of the broader context within which fertility decisions are made and the particular social and cultural behaviours that are the more proximate determinants of reproductive behaviour. The approach to human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) is an example of how studies in the 1980s resurrected the image of African sexuality, which was an explanation of an earlier generation of Europeans trying to understand the spread of syphilis in Africa. That there were certain structural forces and conditions behind the shaping of sexual behaviour was not quite understood. Packard's paper raises many questions. But one can hardly disagree with him when he says, What one views as a social determinant of health, how widely one casts one's net is very much determined by where one sits politically, geographically and intellectually.
If Packard's paper on Africa and Imrana Qadeer's paper on India underscore the politics of health in the changing global scenario as well as the ideological underpinning in the understanding of a policy on health, the paper on Health Determinants in Urban Areas: Combined Effects of Social, Spatial and Temporal Dimensions by Roderick J. Lawrence is somewhat disappointing as it fails to make the connections that underlie the social determinants of health. It is rather uncritical of urban life and assumes rather simplistically that improved access to medical services is a common characteristic of urban neighbourhoods that is rare in rural areas.
The paper seems to indicate that paucity of research in the area of interventions required to promote health in urban areas is somewhat responsible for the poor state of urban health services. This is the main limitation of Lawrence's approach,
His other argument, that the social determinants of health have locality-specific characteristics and hence require area-based interventions somehow runs contrary to the belief that they, barring certain specific cultural factors that may contribute to but not necessarily determine health outcomes, are very much universal in character.
POLITICS OF HEALTHThe politics of health resonates in the papers by Patrice Bourdelais and Simon Szereter; the latter even makes out a case for identity registration as a tool of economic opportunity and argues that poor countries cannot afford not to invest in an identity registration system. This argument is somewhat relevant in the Indian context, especially as a move to have a unique identification card as a mark of nationality has been received with scepticism.
Alison Bashford's paper focusses on the policies in 19th century Australia. She argues that the state used public health measures to benefit the settler population as opposed to Aborigines, which resulted in a 20-year life expectancy gap between the settlers and the indigenous people and this persisted over generations.
The History of Social Determinants and Health in Europe: A Swedish Example, authored jointly by Jan Sundin and Sam Willner, looks at the material and social conditions that shaped health outcomes in 19th century Sweden.
The paper, which is representative of Europe, argues that class as a concept that encapsulates not only income and wealth but also cultural resources like education is generally related to survival rates.
It says that local customs might explain certain geographical patterns, but once population density ceases to be the overshadowing factor, indicators of material wealth positively correlate with life expectancy.
Before the decline in the rate of mortality in the 19th century, infant and child mortality rates in Sweden were high in all social groups; once the decline started, class became more important. The paper argues that public health campaigns and advice, be it for breastfeeding, hygiene or smallpox vaccination, seem to have reached the urban middle class before it reached craftsmen and workers.
Taking the argument of differential entitlements in unequal societies, Virginia Berridge, in her paper that reinterprets The Black Report, argues how in the 1980s and the early 1990s the political language in the United Kingdom was of variations in health and not inequalities. She writes about political inequalities, political choices and the role of science in defining these choices. This report was set aside by the Tory government of Margaret Thatcher but led to a debate on the social determinants of health.
Kasturi Sen's paper looks at conflict-ridden Lebanon as an example to underscore the message of war as a long-term health determinant for people exposed to chronic conflict, while Roderick Lawrence's paper looks at spatial, social and temporal factors as influences on urban health, with a focus on the localities inhabited by social classes. Anne-Emanuelle Birn's work on Uruguay in 1924 and 1940 examines the folly of vertical programmes and the consequences of such policies on infant mortality.
Apart from the region-specific studies, the volume also includes two new approaches to oral history. The underlying commonality in all the papers, as pointed out in the foreword by the Chair of the Commission, Sir Michael Marmot, is that broad social conditions are important influences on health. In fact, Stephen J. Kunitz says in Sex, Race and Social Role: History and the Social Determinants of Health that the significance of sex, race and social roles is shaped by the historical, socio-economic, cultural and epidemiological context, among others thnigs. There are also determinants other than the social.
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