BOOK REVIEW
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Making Sense of Social Determinants
Rajib Dasgupta
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Predictors of Health
Social determinants of health is a wide and complex field of enquiry; social class, caste, gender, ethnicity, education, infrastructure and access to public health services – to name a few. The emergence of life course epidemiology along with the social determinants framework have highlighted that socioeconomic position is a powerful predictor of health. Such analyses pose metho dological challenges, requiring data sets that often require repeat measures of exposures and/ or outcomes. They offer an opportunity to
History of the Social Determinants of Health: Global Histories, Contemporary Debates
edited by Harold J Cook, Sanjoy Bhattacharya, Anne Hardy (Hyderabad: Orient Blackswan), 2009; pp 364, Rs 895.
examine and understand dynamic processes and locate sensitive or critical periods. Modern epidemiology often seems more concerned with modelling complex relationships among risk factors than with understanding their origins and implications for public health. The belief that population patterns of health and disease can be explained by a web of interconnected risk and preventive factors has become a central theme of epidemiology and is embedded in statistical techniques. Its corollary is that epidemiology’s role in improving public health rests upon its ability to identify and predict the results of breaking selected strands of this causal web; often, in a hurry to feed into policy. These papers explore a wide range of determinants, and indeed some unconventional ones like war, representing some “new thinking”. While in one sense social determinants is as old as public health itself, the brave new era of CSDH has provided the opportunity for it to emerge “from the underground”.
In his foreword Michael Marmot, Chair, CSDH has pointed out the need for locating historical necessity in order to develop an
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understanding of the social determinants across diverse populations, periods and contexts – and that in essence is the contribution of this volume. Social action therefore needs to be based on a variety of evidence, including that of a historical nature. Marmot has however cautioned
about venturing into forming universal relationships between social determinants and health. The introduction by the three editors underscores the relevance of complementing historical evidence with epidemiological data (that the CSDH has meticulously collated and analysed), drawing upon the McKeown debate as an illustrative case. This chapter also describes the background and process of the conference and the need for drawing upon new approaches to oral history that can have significant applications.
Historical Approach
The first group of papers analyse historical approaches of social determinants in the context of regions of the world – Australasia-Oceania, Asia, Africa and Europe. In the context of social determinants, it is customary to examine the cases of Europe and Britain; the papers on the other regions are therefore a significant contribution, particularly given the paucity of quality data. They have dealt with issues on a broad canvas – examining colonialism as a historical determinant, the complex interplay of nutrition, fertility and mortality and the social determinants of HIV/AIDS in Africa. Paul Greenough makes an interesting analysis of intra-household survival logics of food distribution in Asia (particularly India and China), Shen Te and Shui Ta – drawing upon Brecht.
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Another set of papers examine the multiple dimensions of history of social determinants of health. Kunitz examines three key determinants – sex, race and social role. He makes an interesting analysis of the case of Yugoslavia where counternationalism emerged among subordinated peoples and led to the dissolution of the country. Analysing life expectancy of birth of the newly formed entities, the paper demonstrates that the Slovenian population showed gains while Serbia’s position worsened in terms of life expectancy. He makes a compelling argument that social theories have not been able to come up with broad principles that can make reliable predictions possible for health consequences of social changes and social policies. Roderick J Lawrence examines the “urban revolution” and its associated phenomena such as “techno-addiction” as another set of determinants. He has drawn upon the bio-historical perspective of Stephen Boyden and has examined a wide range of relationships – social, spatial and temporal on the one hand and epidemiological, psychological and sociological on the other.
Four papers have dealt with a diversity of political and development determinants and their relationship to health of populations in considerable depth. Anne-Emanuelle Birn and Imrana Qadeer present the cases of Uruguay and India, respectively, both of them incisive in their analyses of the differing strategies and trajectories of the welfare state and concerns about marginalised groups. Birn locates the emergence of child health as a critical area of public health in 19th century Uruguay and the varying trends of infant mortality rate (IMR) in the backdrop of different strands of development models pursued by the welfare state. The welfare state occupies centre stage in the discussion of both these papers. Birn argues that U ruguay, a non-industrial state transformed to a universal, entitlement basis; that a strong universal, rights-based approach backed by strong, national governments is crucial to translate into health gains. Analysing the Indian experience (with relatively strong national governments, though current trends of relatively un stable coalition governments could potentially reverse some of the health gains as Birn cautions) Qadeer questions the “mirage of development” in general and health sector reforms in particular. She makes the argument that concerns for health of the marginalised may continue to be marginalised since there is no d emonstrable evidence in the country yet of adversely affecting economic growth, the raison d’etre of the neoliberal reforms regime. Yet, ironically, distortions in growth coupled with health sector r eforms could “destroy labour, the very e ssence of capital”.
Simon Szreter in his paper argued that the English Poor Laws, suitably supplemented by the Settlement Acts, contributed to the mobility of labour as the welfare nature of Britain matured. The northsouth divide (within the country) in d ifferential implementation of relief
Centre for Women’s Development Studies
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Centre for Women’s Development Studies (CWDS) is pleased to announce its participation in offering the IGNOU-CWDS Ph.D. Programme in Women’s Studies from the academic year 2009-10, through an MoU signed with the Indira Gandhi National Open University, New Delhi.
Interested candidates should consult the websites of IGNOU and CWDS for information regarding eligibility of candidates. Besides the minimum criteria laid down by the university for admission to all Ph.D programmes, screening will be done based on the following criteria – academic performance at M.Phil/Master’s level, postgraduate degree in relevant discipline, no. of years of teaching experience, and demonstrable evidence of research publications/interest in women’s and gender issues. Candidates without the M.Phil degree and/or sufficient exposure in women’s studies may be asked to take required coursework before proceeding to doctoral research. Selections will be done on the basis of the above criteria by a screening committee, as per IGNOU admission procedures.
All candidates for the IGNOU-CWDS programme should send a research proposal as part of their application. Application forms should be downloaded from the IGNOU website at www.ignou.ac.in and a copy sent to both IGNOU and CWDS. While applications are accepted throughout the year, candidates may be admitted in either the July or the January session, depending upon the receipt of application and completion of registration procedures.
This notification is particularly meant for candidates who wish to apply in time for the July Session. Kindly check CWDS website for further information.
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m easures resulted in adverse outcomes. The paper strongly advocates the identity registration system and collective social security systems since their absence can be considered a fundamental development obstacle. The Gates Foundation funded Health Metrics Network is a step in that direction. Such systems are crucial to collect evidence; the Final Report of the CSDH has called for basic systems to register all births and deaths, since,
Action on the social determinants of health will be more effective if basic data systems, including vital registration and routine monitoring of health inequity and the social determinants of health, are in place and there are mechanisms to ensure that the data can be understood and applied to develop more effective policies, systems, and programmes.
The paper by Virginia Berridge (on the Black Report) demonstrates the application of newer historical techniques – the witness seminar technique. The last two chapters describe these new methodologies. The witness seminar technique can be a powerful tool in exploring and analysing recent and contemporary p ublic health issues/programmes that are often mired in controversy – both technical and sociological. Technology may emerge as a critical social determinant; controversy and confusions over oral polio vaccines (and their dosages) is a contemporary example, where techniques such as these may deconstruct i ssues in a participatory framework.
Actionable Evidence
This volume is a valuable and powerful addition to the fast expanding literature on social determinants of health. The failure of the principles and practice of the spirit of Alma Ata, as some scholars have argued, is at least in part due to the “serious crisis in the practice of international health by the World Health Organisation”. This volume applies some of the “historical sciences”, on which social epidemiology is largely foregrounded (as Birn emphasises), to understand trends and phenomena in the probabilistic world we live in, but seldom acknowledged by a deterministic biological framework that contemporary public health seems to increasingly rely upon. One uniform theme that runs through the papers is that experiences of peoples, places, local levels and contexts can ordain some modicum of predictive abilities of social determinants
Sage
of health. It is a valuable addition to “actionable evidence” that has put politics centre stage in unequivocal terms. It is not often that history is considered as a “cause of causes”, upfront that is. This volume makes a powerful case for “conciliance” as Simon Szreter argues in another context:
a situation where the use of independent forms of evidence, sometimes of a d iverse (and non-quantitative) form – any one element of which may not be persuasive alone produces a triangulation effect, unanimously confirming from these different perspectives empirical correspondence with the truth of an analytical statement or causal proposition.
Making sense of social determinants, more so their histories, is not an easy task. The 2006 Conference and the editors have made it possible for these public health philosophers to put their expertise and experience together to contribute to this well-crafted volume; a must-read to gain a comprehensive historical perspective to social determinants of health
– as much for diehard believers as for recent converts.
Email: dasgupta_jnu@yahoo.com
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