Barriers to Addressing the Social Determinants of Health:

Insights from the Canadian Experience

Dennis Raphael, Ann Curry-Stevens, Toba Bryant

Manuscript

Abstract
Despite Canadas reputation as a leader in health promotion and population health,
implementation of public policies in support of the social determinants of health has been
woefully inadequate. The continuing presence of income, housing, and food insecurity has led to
Canada being the subject of a series of rebukes from the United Nations for failing to address
child and family poverty, discrimination against women and Aboriginal groups, and most
recently the crisis of homelessness and housing insecurity. In this article we consider some of the
reasons why this might be the case. These include the epistemological dominance of positivist
approaches to the health sciences, the ideology of individualism prevalent in North America, and
the increasing influence on public policy of the marketplace. Various models of public policy
provide pathways by which these barriers can be surmounted. Considering that the International
Commission on the Social Determinants of health will soon be releasing its findings and
recommendations, such an analysis seems especially timely.

Introduction
Despite Canadas reputation as a leader in developing and promoting health promotion
and population health concepts, implementation of public policies in support of health has been
woefully inadequate (Canadian Population Health Initiative, 2002). The continuing presence of
income, housing, and food insecurity among Canadians has led to Canada being the subject of a
series of rebukes from the United Nations for failing to address child and family poverty,
discrimination against women and Aboriginal groups, and most recently the crisis of
homelessness and housing insecurity (D Raphael, 2007c).
The contrast between words and actions has also been apparent in the area of the social
determinants of health (D Raphael, 2007a). Canadas rich history of policy declarations
regarding the importance of public policy for addressing the economic and social conditions
underlying health has contributed to the social determinants of health concept (Epp, 1986; Health
Canada, 2001; Lalonde, 1974). Canadians have been chosen to manage two of the International
Commission on the Social Determinants of Healths knowledge hubs and Canadians are making
significant contributions to various aspects of the Commissions mandate (World Health
Organization, 2004).
Yet on the ground, living conditions continue to deteriorate for many Canadians (D
Raphael, 2007a, 2007c; United Way of Greater Toronto & Canadian Council on Social
Development, 2002). As just one example, Statistics Canada recently reported that over the past
ten years the only group of Canadians showing income gains has been the top 20% whose
incomes have increased substantially (Murphy, Roberts, & Wolfson, 2007). The incomes of the
other 80% of Canadian have stagnated. Analyses of Canadian failures to address the social
determinants of housing, employment security, food security, social exclusion, and poverty
among others are available (D. Raphael, 2004; D Raphael & Bryant, 2006).
Considering the accumulating knowledge of the importance of the social determinants of
health and Canadas reputation for considering these issues on a conceptual level, how can we
explain Canadas public policy failure to address these issues? In this paper we consider two key
questions. Considering what is known about these social determinants of health and their
importance for promoting the health of Canadians, why does there seem to be so little action
being undertaken to improve them? and (b) What are the means by which such public policy
action in support of health can be brought about? Such an analysis seems especially timely what

with the International Commission on the Social Determinants of Health coming closer to
offering its sets of reports and recommendations. What might be the barriers to having its
findings and recommendations accepted?

Identifying the Issues

Our analysis considers issues that are only sporadically discussed in the health sciences
literature but appear especially important to implementing strengthening the social determinants
of health agenda. The first issue considers the role that professional and societal discourses
ways that health professionals, the public, and policymakers understand and consider an issue
play in having a concept such as the social determinants of health taken seriously (Bryant, 2002;
Nettleton, 1997; Tesh, 1990). What are the ideas about health and illness the ideologies -- held
by health professionals, the public, and policymakers concerning the sources of health and
causes of disease? How do these ideas influence receptivity to a social determinants of health
approach to promoting health?
This analysis is important as there are numerous aspects of a social determinants of health
approach that are foreign to traditional ways of thinking about health issues in North America.
Some of these aspects include (a) how issues in the health sciences in general, and in
epidemiology in particular, are generally conceived and acted upon; (b) the role that the belief in
individualism and individual responsibility play in North American society; and (c) the
increasing market orientation of North American society and how this emphasis weakens support
for a social determinants of health approach to promoting health.
The second issue is concerned with what is known about the policy change process in
Canada and other developed nations. There are varying approaches to understanding the policy
change process (Brooks & Miljan, 2003). The pluralist approach sees policy development as
driven primarily by the quality of ideas in the public policy arena such that those judged as
beneficial and useful will be translated into policies by governing authorities The materialist
approach is that policy development is driven primarily by powerful interests who assure their
concerns receive rather more attention than those not so situated. In Canadian society these
powerful interests are usually based in the economic market sector and have powerful partners in
the political arena. The public choice view of policymaking tries to get into the heads of
policymakers to understand why they move on some issues and not others. Each approach
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provides differing explanations for understanding the present situation and each proposes
different means of moving a social determinants of health agenda forward.
The pluralist approach suggests the need for further research, knowledge dissemination,
and public policy advocacy with the aim of convincing policymakers to enact health-supporting
public policy (Wright, 1994). The materialist model suggests the need for developing strong
social and political movements with the aim of forcing policymakers to enact health-supporting
public policy. The public choice model has little to say about raising these issues but can be
drawn upon to develop ways of understanding and influencing policymakers decision processes.
The third issue is the increasing influence of neo-liberal market-oriented ideology upon
the making of Canadian public policy (Teeple, 2000). The last two decades has seen a
diminishing role of the State in citizen provision of resources. This has been associated with
program reductions, limiting eligibility for a range of benefits, and a shifting of influence
towards the business sector rather than institutions associated with civil society (Hofrichter,
2003). Such shifts have been associated with public policymaking that has little to say about
strengthening the social determinants of health (McBride & Shields, 1997). We consider each of
these in turn followed by suggestions on how these influences can be neutralized such that public
policy in support of the social determinants of health can be developed.
Ideology, Health Discourses, and the Social Determinants of Health
Most of the public probably believes that academic disciplines such as the health sciences
and their applied expressions, public health agencies and governmental health ministries, carry
out their activities based on objective facts drawn from empirical research studies. Within this
framework we would understand the health fields current preoccupation with biomedical
advances and with what sociologist Sarah Nettleton (Nettleton, 1997) calls the holy trinity of
risk of tobacco, diet, and physical activity as reflecting the accumulated evidence that these
domains are the primary determinants of citizens health status in developed nations. We would
also understand the profound neglect by the health sciences, public health, and governmental
health authorities of the social determinants of health in Canada as reflecting a lack of evidence
these issues play an important role in determining the health status of Canadians.
Clearly, the evidence concerning the importance of the social determinants of health does
not support this argument (Davey Smith, 2003; Marmot & Wilkinson, 2006; D. Raphael, 2004;

Wilkinson & Marmot, 2003). There must be more to this neglect of the social determinants of
health than meets the eye and indeed, numerous hypotheses are available to inform this analysis.
The first concerns the nature that is the focus and the analytical tools available of research
and action in the health sciences in general and epidemiology in particular.
The characteristics of traditional health sciences and epidemiological approaches that are
problematic have been identified (Bezruchka, 2006; D. Raphael & Bryant, 2002; Tesh, 1990).
These include (a) reliance on quantitative and statistical approaches to understanding health and
its determinants; (b) a tendency towards viewing the sources of health and illness as emanating
from individual dispositions and actions rather than resulting from the influence of societal
structures; (c) a professed commitment to objectivity or what is termed a non-normative
approach to health issues; and (d) a profound de-politicizing of health issues. All of these reflect
an adherence to positivist science as the preferred means of understanding health and its
determinants (J Wilson, 1983).
The health sciences in general and epidemiology in particular are a reflection of what has
been termed positivist science (J Wilson, 1983). Positivist science is based on a natural sciences
approach associated with the rise of physics, chemistry, and biology as areas of study. It is
focused on the concrete and observable. It has also been called a reductionist approach whereby
effort is expended to identify specific variables that can be placed into statistical equations in
order to identify putative causes and effects. While positivist science has led to impressive
advances in the natural sciences, its application to the fields of the health sciences and other
areas of social inquiry has been problematic (D. Raphael & Bryant, 2002).
When applied to the health and social sciences, positivist science generally avoids
dealing with aspects of broader environments (Lincoln & Guba, 1985). In the medical field it
leads to a focus upon cells, body organs, and bodily systems by biomedical researchers and a
focus on behavioural risk factors by health sciences researchers (Bezruchka, 2006; Labonte,
1993). The study of environments and the political, economic, and social forces that shape the
quality of these environments is generally neglected (Navarro, 2004). Examination of, and
attention to environments and the public policies that shape these environments including the
social determinants of health -- is uncommon (D Raphael & Bryant, 2006). Positivist health and
social science also avoids analysis of the abstract, implying the study of the underlying
economic, political, and social structures of society are beyond its analytical and methodological

grasp (J. Wilson, 1983). The role of politics and political ideology in shaping these environments
therefore, is especially uncommon though excellent examples do exist (C. Bambra, 2004; Clare
Bambra, Fox, & Scott-Samuel, 2005; Navarro, 2002, 2007; Navarro & Muntaner, 2004).
Another important aspect of positivist science is its professed commitment to objectivity
(J Wilson, 1983). This leads to researchers and workers being unwilling to make what are
termed normative judgments as to what should be as opposed to describing what is. This
professed commitment to objectivity and avoidance of normative judgments is a pretense as all
health science researchers and public health workers identify their clear commitments to
promoting treatments regimens to improve biomedical markers and to reduce so-called risk
behaviours such as tobacco and excessive alcohol use, physical inactivity, and diets lacking fruits
and vegetables. These commitments to the importance of biomedical markers and behavioural
risk factors and the neglect of broader issues is so strong as to constitute in itself a normative
ideology of what is a health issue and what is not (Hofrichter, 2003; Tesh, 1990). This is -- by
any analysis -- not an objective approach to understanding and promoting health.
The professed commitment to objectivity therefore, serves as a means to avoid
consideration of broader issues concerned with political, economic, and social issues. Also
unlikely to be discussed is how the class biases of health researchers and workers come to
influence what is conceived as being either within -- or outside -- the realm of health sciences
inquiry (Muntaner, 1999). A perceived threat to career prospects that may arise by raising
broader issues associated with the social determinants of health is also not to be dismissed (D
Raphael, 2003). Extensive discussions of how these issues shape the health sciences and public
health sectors apparent unwillingness to consider a social determinants of health approach are
available (D. Raphael, 1998, 2002; D Raphael, 2003).
Within the traditional health sciences approach, health problems remain individualized,
localized, de-socialized, and de-politicized (Hofrichter, 2003). Notice that such an approach is
congruent with conservative and neo-liberal political ideology whereby social problems are
being continually framed as individual ones rather than societal ones (e.g., unemployment,
poverty and racism, etc.). Policy solutions under conservative and neo-liberal ideologies are
residual and de-socialized. This means that government support to deal with the fall-out of
social problems is continually eroded as exemplified by the increasing ineligibility of many
Canadians to access unemployment insurance or increasing difficulty students experience in

financing their education. Frequently, these developments are explicit such as outright
cancellation of progressive policies or social policy or these are done by stealth, meaning
programs become prey to initiatives such as claw-backs, de-indexation or incremental cuts.
While traditional health science approaches may not be overtly conservative in orientation, they
are congruent with such an ideology and serve to justify the retreat of governments around the
world from investing in our collective health and well being (Coburn, 2004, 2006a; Hofrichter,
2003; D Raphael, 2006b; D Raphael & Bryant, 2006; Seedhouse, 2003).
Individualism and the Social Determinants of Health
The second barrier to having a social determinants of health approach taken seriously by
professionals, the public, and governmental policymakers is the North American commitment to
the ideas of individualism and individual responsibility as opposed to communal responsibility
(Hofrichter, 2003). Individualism is the belief that ones place in the social hierarchy their
occupational class, income and wealth, and power and prestige as well as the effects of such
placement such as health and disease status comes about through ones own efforts (Travers,
1997). At the very minimum it leads to placing the locus of responsibility for ones health status
within the motivations and behaviours of the individual rather than health status being a result of
how a society organizes its distribution of a variety of resources.
The importance of individualism to understanding how the determinants of health are
conceptualized has been thoughtfully explored by Hofrichter:
Individualism, a powerful philosophy and practice in North American, limits the public
space for social movement activism. By transforming public issues into private matters
of lifestyle, self-empowerment, and assertiveness, individualism precludes organized
efforts to spur social change. It fits perfectly with a declining welfare state and also
influences responses to health inequities. From this perspective, each person is self
interested and possessed of a fixed, competitive human nature. Everyone has choice and
the potential for upward mobility through hard workignoring how we develop
through the process of living in society. Individualism presumes that individuals exist in
parallel with society instead of being formed by society (Hofrichter, 2003) p. 28).

Individualism in health has numerous effects in relation to the social determinants of

health. First, it leads to a strong bias towards understanding health problems as individual
problems rather than societal ones. Second, it specifies the cause of the health problem as
residing within faulty biomedical markers, specific individual motivations, and risk behaviours
that are somehow under individual control. Third, it specifies that improving health will result
from modifying these markers, motivations, and behaviours. Fourth, it says little about
reorganizing society and its structure in the service of health. Fifth, it says even less about how
such societal structures could be modified.
An alternative paradigm for understanding health and its mainsprings is available.
Sociologists and social epidemiologists working in the historical materialist tradition have long
attempted to illuminate how various modes of production, especially in capitalist societies,
influence the distribution of economic, social, and political resources within the population,
thereby influencing health (see (D Raphael, 2006a). Despite this long-standing tradition, these
analyses concerning the structural determinants of healthand their clear impacts on health -remain outside the mainstream of current discourse on determinants of health among
policymakers and health researchers in Canada. It is unclear whether the efforts associated with
the International Commission on the Social Determinants of Health can reverse this tendency.

Increasing Market Orientation of Canadian Society

Finally, the increasing market orientation of Canadian society weakens support for a
social determinants of health approach to promoting health.(Coburn, 2004; Scarth, 2004; Teeple,
2000) The rise of capitalism and the market economy grew in tandem with a strong belief in
individualism and the ability of the individual to control ones destiny (Esping-Andersen, 1990).
The uncritical belief in this ideology was associated with the rise of market-oriented societies
which saw little role for governmental or state intervention in the market place and in the
provision of various forms of security for its citizens. At its heyday such a belief saw the rise of
tremendous inequalities in wealth and health in Victorian England, for example, and more
recently during the 1930s and since the 1970s in many developed nations (Alesina & Glaeser,
2004).
The rise of differing forms of welfare states in Europe during the 19th century was a

response to these excesses of laissez-faire capitalism (Esping-Andersen, 1990). In continental

Europe a conservative form of the welfare state arose whose main concern was with reducing
unrest and promoting a modicum of security for citizens. The dominant ideological inspiration
of this type of welfare state has been identified as Solidarity achieved through social stability,
wage stability, and social integration (Saint-Arnaud & Bernard, 2003).
In Scandinavia the social democratic welfare state arose which saw active promotion of
equality and human rights and the provision of citizen security across the life span (EspingAndersen, 1985). There, the dominant ideological inspiration is Equality achieved through the
reduction of poverty, inequality, and unemployment (Saint-Arnaud & Bernard, 2003). The third
form of the welfare state the liberal was the weakest of all and Canada falls within this group.
In the liberal welfare state the dominant ideological inspiration is Liberty achieved through
minimizing governmental interventions, and minimizing so-called disincentives to work such
as social programs and supports.
The liberal welfare state and its associated ideology provide barren soil for a welldeveloped social determinants of health approach. Within such an approach, liberty and its close
neighbor, self-determination, become available only to a narrow band of the population those
who have sufficient financial resources and cultural capital to define their own living conditions
(Coburn, 2006b). Liberty and self-determination are out-of-reach for much of the population.
Scholarship has specified the mechanisms by which these differing forms of the welfare
states developed and how their trajectories shape the making of public policy (Esping-Andersen,
1990). Importantly, these differing forms of the welfare state have been shown to be related to
clear differences in the quality of numerous social health determinants of health and population
health outcomes (Esping-Andersen, 1999; Navarro et al., 2004).
Even so, the end of the Second World War saw a clear desire by all nation states to avoid
the economic and social conditions that gave rise to totalitarianism (Teeple, 2000). Attention to
promoting citizen security was increased across all developed nations such that by the 1970s the
Canadian welfare state was seen by some as rivaling that of Sweden at the time.
Yet the rise of what has been termed neo-liberalism or a retreat from government
intervention in the marketplace -- has threatened these social reforms (Coburn, 2004; Teeple,
2000). This has especially been the case in the liberal political economies such as Canada. Neoliberalism refers to the dominance of markets and the market model. According to Coburn

(2000), the primary tenets of neo-liberalism are: 1) markets are the best and most efficient
allocators of resources in production and distribution; 2) societies are composed of autonomous
individuals (producers and consumers) motivated chiefly or entirely by material or economic
considerations; and 3) competition is the major market vehicle for innovations. Such ideology
sees little space for governmental action in strengthening the social determinants of health.
Conservative and social democratic political economies have been more able to resist
these forces than liberal political economies (Vandenbroucke, 2002). Consistent with this view,
it has been argued that Canadian society is moving more and more towards that of the most
extreme liberal welfare state, the United States (Scarth, 2004). It should therefore not be
surprising that implementation of a social determinants of health approach has been lacking in
Canada (Canadian Population Health Initiative, 2002). Those attempting to raise these issues
through the provision of evidence and policy options run smack into resistance driven by
ideological beliefs concerning the nature of society as well as concrete pressures to resist such an
agenda. Some of these concrete forces become clearer in the following examination of how
public policy is made in nations such as Canada.
Understanding Policy Change
Another key issue is the policy change process in Canada and other developed nations.
There are varying approaches to understanding the policy change process (Brooks & Miljan,
2003). The pluralist approach sees policy development as driven primarily by the quality of
ideas in the public policy arena such that those judged as beneficial and useful will be translated
into policies by governing authorities. An alternative materialist approach is that policy
development is driven primarily by powerful interests who assure that their concerns receive
rather more attention than those not so situated. The public choice model tries to get into the
heads of policymakers and focuses on the process by which they develop and implement policies
that maximize the benefits to society (Brooks & Miljan, 2003).
Each approach provides differing explanations for understanding the present situation and
each proposes different means of moving such an agenda forward. As noted the social
determinants of health appear to be underdeveloped in Canada as compared to most other
developed nations. Much of this has to do with public policies that determine how the resources
of the nation are to be distributed among the population.

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Pluralist View
The pluralist view is that public policy decisions result from governments and other
policymakers choosing public policy directions based on the competition of ideas in the public
arena (Brooks & Miljan, 2003). This competition of ideas according to this view is facilitated by
various interest groups who lobby governments to accept their position. Pluralists recognized
that there may not be a level playing field in these lobbying attempts with political, economic,
and social elites having an upper hand. Nevertheless the pluralist approach assumes that the
governmental policymaking process is generally open and those with the better ideas will come
to see their views adopted by governments.
Additionally, pluralists assume that policymaking is a democratic and rational process
whereby the best ideas are put into practice. Individuals, communities, agencies, organized
groups, labour and business all have a place at the policymaking table. Canadian governments
are not seen as being the handmaiden of the elites. Rather they strive to implement the Canadian
constitutional principles of peace, order, and good government by implementing reasonable
public policy. If Canada lags behind in social determinants of health supportive policy, it
requires education of policymakers and lobbying of these same policymakers with the
expectation that with the right knowledge dissemination, translation, or exchange, these health
supportive policies will come to pass. The pluralist view argues therefore that advocates of the
social determinants of health view need to get organized and have their voices heard by
policymakers. Ongoing consciousness raising, advocacy and lobbying and building coalitions
will achieve policy change.
Taking this view at face value, we would expect that all of the policy recommendations
presented by various Canadian writers would be of interest to policymakers (Campaign 2000,
2004a, 2004b; Canadian Association of Food Banks, 2005; D. Raphael, Bryant, & CurryStevens, 2004; Dennis Raphael & Curry-Stevens, 2004). The only problem is that these policy
options have been presented numerous times over the past decade to policymakers, their benefits
have been outlined repeatedly, yet no action seems forthcoming. For example Raphael and
Curry-Stevens suggested a number of options that would strengthen the social determinants of
health (see Table 1).
Yet, there is little evidence that any of these recommendations have been taken seriously. Why is

11

this the case? Perhaps we need an alternate model of policy change to explain the current
situation and point the way forward. The materialist model provides such an alternative.
<<insert Table 1 about here>
The Materialist View
The materialist view is that governments in capitalist societies such as Canada enact
policies that serve the interests of economic elites (Brooks & Miljan, 2003). These elites are the
owners and managers of large corporations whose primary goals are to maximize profits, provide
growing profits to shareholders, and institute public policies that keep business costs down.
These interests are also likely to lobby for minimal governmental intervention in business
practices and to resist business regulation and progressive labour legislation (Langille, 2004).
Lowering corporate and income taxes is also an important policy objective. Since taxes are
required to fund governmental services, economic interests frequently call for reduction in
program spending to allow tax decreases. Business interests generally oppose moves that enable
workers to form unions that would see the realization of collective bargaining. Collective
bargaining is related to the receipt of higher wages, stronger benefits and increased employment
security for union members. We have come through a generation of governments retreating from
their role in supporting its most vulnerable citizens, and even much of the middle class.
Canadians have seen a dramatic set of cuts to progressive taxes such as income tax and
corporate taxes, and a correlated rise in regressive taxes such as the GST. We have also seen
massive cuts to income support programs such as social assistance (in most provinces) and
unemployment insurance. On the program side, extensive cuts have been made to public
housing, education, mental health and violence against women services (Scarth, 2004). Failed
promises in child care and supports for the homelessness reveal that even when gains are made
through social movements, governments can undo them through an array of means. Labour
legislation has been rolled back in many provinces, undoing gains made in the post-war era.
Economic interests are able to influence governments through a variety of processes.
First, they are able to influence government through their ability to shift investment capital from
location to location. A government that institutes non-business friendly policies could see
business and investment leaving the jurisdiction. Second, lending agencies whose interests are
consistent with business can raise borrowing rates for debt-ridden jurisdictions that institute what
they see as problematic policies. Third, the people who have the financial resources to consider

12

running for the dominant political parties may either come from the business class and/or hold
values. These individuals can not only expect to receive financial support for their runs at
political office, but can also be assured of employment opportunities within these same sectors if
they fail to be re-elected or upon their retirement from public office (D Raphael, 2007b).
Increasing income and wealth inequality and the weakening of social infrastructure result
from the concentration of wealth and power within a nation with attendant weakening of civil
society (Phillips, 2003; D Raphael & Bryant, 2006). What is to be done? The materialist model
suggests organizing the population to oppose and defeat the powerful interests that influence
governments to maintain poverty (Wright, 1994). These defeats can occur in the workplace
through greater union organizing and the promotion of class solidarity. These defeats can occur
in the electoral and parliamentary arena by the ascendance of working class power.
This would come about by achieving greater equity in political power (Zweig, 2000).
This can be achieved by restoring programs and services and reintroducing more progressive
income tax rates. Independent unions are a necessity as is legislation that strengthens the ability
of workers to organize. Re-regulating many industries would reverse current trends towards the
concentration of power and wealth. Internationally, the development and enforcement of
agreements to provide adequate working and living standards that would support and promote
health and wellbeing across national barriers is essential.
The provision of a social wagegovernment provided services that people need to live
and develop their ability to workis a way to restore the social infrastructure that has been so
weakened in nations such as Canada. Resistance to the privatization of public services is
essential.
Public Choice Model
The public choice model focuses on the individual policymaker and the process by which
they develop and implement policies that maximize the benefits to society (Brooks & Miljan,
2003). In this model the policymaker looks out societys as well as his or her own interests by
balancing the interests of a wide range of stakeholders: various interest groups including
business, labour, the needs of elected officials and senior civil servants, and the media, among
others. The public choice model would suggest that it is not in the overall interests of Canadian
policymakers to address the social determinants of health. People who experience poor quality

13

determinants have little influence with policymakers since their concerns are not seen as being
the concern of most Canadians, and in any event these people are less likely to vote. In contrast
those interests who experience weak social determinants, these interests are highly organized, are
able to exert influence upon policymakers, thereby controlling the public policy agenda. Put
simply, raising and addressing social determinants of health issues provides little benefit for
governing parties. The public choice model argues that policy dynamics must change such that
policymakers who do not address poverty will suffer consequences and their political masters
will experience electoral consequences.
The Way Forward
Such an analysis suggests that what is necessary to promote governmental receptivity to
the social determinants of health concept is the building of social and political movements in
support of health. There is some evidence that the social determinants of health concept has
contributed to this. Numerous Canadian social development and social justice advocacy groups
as well as public health units have taken up the social determinants of health concept in support
of their activities (Association of Ontario Health Centres, 2007; Chronic Disease Alliance of
Ontario, 2007; Interior Health Region, 2006; O'Hara, 2006; Registered Nurses Association of
Ontario, 2007; Sudbury and District Health Unit, 2006; Waterloo Region Public Health Unit,
2002).
In this section we focus on what role health researchers and workers could play in this
public policy arena. These three roles are education, motivation, and activation in support of the
social determinants of health. These roles are about building the social and political supports by
which public policy in support of the social determinants of health could be implemented. Each
is considered in turn. As noted, such action will require broadening of knowledge paradigms in
the health sciences, accepting the political nature of health and its determinants, and confronting
many of the economic and social forces that are opposed to governmental action in the service of
strengthening the social determinants of health.
Educate
In Canada and other nations governed by liberal political economies, the public remains
woefully uninformed about the social determinants of health (Canadian Population Health

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Initiative, 2004; Eyles et al., 2001; Paisley, Midgett, Brunetti, & Tomasik, 2001). The population
has also been subject to continuous messaging as to the benefits of a business-oriented laissezfaire approach to governance (Teeple, 2000). What this messaging has not included are the
societal effects of this approach: increasing income and wealth inequality, persistent poverty, and
a relatively poor population health profile (Coburn, 2006). These effects are profound and
objectively influence for the worse the health and well-being of a majority of the population
(Esping-Andersen, 1999).
There are hundreds if not thousands of Canadians whose occupations are concerned
with the health of the public. These workers could take advantage of the citizenrys continuing
concern with health and the wealth of evidence of the importance of the social determinants of
health to begin offering an alternative message to the dominant biomedical and lifestyle
discourse. At a minimum health promoters can carry out and publicize the findings from -critical analysis of the social determinants of health and disease. This is not a question of being
subversive it is rather a simple matter of information and knowledge transfer.
There is no shortage of areas in which health researchers and workers could engage:
social determinants of health such as poverty, housing and food insecurity, and social exclusion
appear to be the primary antecedents of just about every affliction known to humankind (G
Davey Smith, 2003). Our short list of such afflictions includes coronary heart disease, type II
diabetes, arthritis, stroke, many forms of cancer, respiratory disease, HIV/AIDS, Alzheimers,
asthma, injuries, death from injuries, mental illness, suicide, emergency room visits, school dropout, delinquency and crime, unemployment, alienation, distress, and depression. Examples of
such analyses and critiques of the dominant paradigms are available (Raphael, 2002; Raphael,
Anstice, & Raine, 2003).
Motivate
Health researchers and workers can shift public, professional, and policymakers focus on
the dominant biomedical and lifestyle health paradigms to a social determinants of health
perspective by collecting and presenting stories about the impact social determinants of health
have on peoples lives. Ethnographic and qualitative approaches to individual and community
health produce vivid illustrations of the importance of these issues for peoples health and wellbeing (Popay & Williams, 1994). There is some indication that policymakers and certainly the

15

media may be responsive to such forms of evidence (Bryant, 2002). In Canada, such research
clearly constitutes a small proportion of public health and health services research (Raphael,
Macdonald et al., 2004).
There is increasing recognition of the importance of community-based research and
action (Minkler, 2005; Minkler, Wallerstein, & Hall, 2002). But frequently, these activities are
narrow and seem unwilling to allow citizens to raise issues of public policy concerned with
income distribution, employment and labour issues, and fundamental questions of citizen
participation in governmental priorities and actions. Such activities can be a rich source of
insights about the mainsprings of health and means of influencing public policy. Such a
perspective allows community members to provide their own critical reflections on society,
power and inequality. At a minimum these approaches allow the voices of those most influenced
by the social determinants of health to be heard and hold out the possibility of their concern
being translated into political activity on their part and policy action on the part of health and
government officials. Ultimately, the end of such activities should be the creation of social
movements in support of health. The Peoples Health Assembly is but one example of such a
movement in support of health (People's Health Assembly, 2005).
Activate
The final role is the most important but potentially the most difficult: supporting political
action in support of health. There is increasing evidence that the quality of any number of social
determinants of health within a jurisdiction is shaped by the political ideology of governing
parties. It is no accident that nations where the quality of the social determinants of health is high
have had greater rule by social democratic parties of the left. Indeed, among developed nations,
left cabinet share in national governments is the best predictor of child poverty rates which itself
is associated with extent of government social transfers (Rainwater & Smeeding, 2003). Nations
with a larger left-cabinet share from 1946 to the 1990s had the lowest child poverty rates and
highest social expenditures; nations with less left-share hade the highest poverty rates and lowest
social expenditures. Canada, like the other liberal nations of New Zealand, Ireland UK, and the
USA is among the lowest nations in left federal cabinet share (0%) and among the highest in
child poverty rates (15%) in the 1990s (providing a poor poverty standing of 19th of 26 OECD
nations).

16

It has also been documented that poverty rates and government support in favour of
health the extent of government transfers is higher when popular vote is more directly
translated into political representation through proportional representation (Alesina & Glaeser,
2004). Canada also does not have proportional representation the lack of which is associated
with higher poverty rates and less government action in support of health. Proportional
presentation is important because it provides for an ongoing influence of left-parties regardless
of which party forms the government.
This analysis recognizes the profound barriers that exist in having the Canadian
government address the socials determinants of health. Dominant ideologies typical of the health
sciences, public attitudes towards personal responsibility, and increasing market influence all
work against having a social determinants of health agenda implemented.
Nevertheless, developments in Europe indicate that concerted public health and
community efforts can profoundly influence the development of policies that determine the
extent of health inequalities and the overall state of population health within a nation. The policy
directions being undertaken by nations such as Sweden and Finland are two such examples
(Government of Sweden, 2005; Ministry of Social Affairs and Health, 2001). Similarly, the
success of the WHO European Office Healthy Cities initiative is another example of the power
of cities and communities to influence health policy (World Health Organization Regional Office
for Europe, 1997, 2003). Canada has a rich history of concerted public pressure that can lead to
positive policy change.
The social determinants of health concept can help make the links between government
policy, the market, and the health and well-being of citizens in Canada and elsewhere. For those
working in the health sector, it can serve as motivation for working for change. The interests of
their clients, patients or consumers are served by speaking out against poverty, social exclusion,
inequality, and inadequate services. There are potent barriers however, to such actions. We hope
this article can assist in recognizing and surmounting these barriers.
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Table 1

Table 1: Policy Options to Support the Social Determinants of Health

Policies to Reduce the Incidence of Poverty

Raise the minimum wage to a living wage.

Improve pay equity.
Restore and improve income supports for those unable to gain employment.
Provide a guaranteed minimum income.

Policies to Reduce Social Exclusion

Enforce legislation that protects the rights of minority groups, particularly concerning
employment rights and anti-discrimination.
Ensure that families have sufcient income to provide their children with the means of
attaining healthy development.
Reduce inequalities in income and wealth within the population, through progressive
taxation of income and inherited wealth.
Assure access to educational, training, and employment opportunities, especially for
those such as the long-term unemployed.
Remove barriers to health and social services which will involve under-standing where
and why such barriers exist.
Provide adequate follow up support for those leaving institutional care.
Create housing policies that provide enough affordable housing of reasonable standard.
Institute employment policies that preserve and create jobs.
Direct attention to the health needs of immigrants and to the unfavourable socioeconomic
position of many groups, including the particular difficulties many New Canadians face
in accessing health and other care services.

Policies to Restore and Enhance Canadas Social Infrastructure

Restore health and service program spending to the average level of OECD nations
Develop a national housing strategy and allocate an additional 1% of federal spending for
affordable housing.
Provide a national day care program.
Provide a national pharmacare program.
Restore eligibility and level of employment benefits to previous levels.
Require that provincial social assistance programs are accessible and funded at levels to
assure health.
Assure that supports are available to support Canadians through critical life transitions.