Beyond health care

Attention should be directed at the social determinants of ill health

The aims of health policy ought not to be contentious. Topping the list should be a commitment to improve the length and quality of life of everyone and to minimise avoidable differences in health status among social groups. The corollaries of such goals include improving our understanding of the determinants of health and intervening in public policy to deliver the required outcomes. Unfortunately, no evidence exists that any political party in Britain has grasped the extent to which thinking must change. Debates about the financing, governance, and structure of the NHS remain as dominant as they are largely unconstructive. What is needed now is a radical change of direction away from tinkering with the organisation of health care towards developing new approaches to health policy.

The importance of this proposition is illustrated in a new book produced under the auspices of the population health programme of the Canadian Institute for Advanced Research. Why are Some People Healthy and Others Not? contains contributions from internationally renowned analysts, including economists, epidemiologists, and political scientists.1

The book's central argument is based on a synthesis of evidence—both familiar and newly emerging—suggesting that “factors in the social environment, external to the health care system, exert a major and potentially modifiable influence on the health of populations, through biological channels that are just now beginning to be understood.”2

Recent scientific advances show ways in which people's perceptions of their social environments can stimulate chemical and electrical responses in their body's endocrine, immune, and neural systems. These new studies lend credence to older ones that have emphasised the health promoting qualities of social support. A key determinant of health turns out to be the extent to which humans and other primates are able to rely on their own resources, or the support of others, to overcome the pressures associated with social and environmental factors.

Why, given that the importance of social and environmental determinants of the health of populations has been known for many years, has policy taken so little account of it? The short answer is that the combination of economic interests and political influence associated with the health care industry is so powerful that a predominantly biomedical system of beliefs dominates the development and practice of health policy.3

We have been indoctrinated into accepting the superiority of biomedical and disease oriented explanations of the determinants of health to the detriment of socioeconomic ones. For example, probably the dominant lay view in modern industrial societies is that the main causes of premature death are cancer and heart disease. The almost inaudible counterview is that the principal killers are the “lack of social support, poor education, and stagnant economies.”4 The result of the bias inherent in the prevailing system of beliefs is that enormous effort is put into researching and marketing such fripperies as cholesterol free crisps. On the other hand, serious study of ways of over-coming the stress associated with hierarchies in the workplace or of providing “companionship and support for the widowed elderly”4 and other vulnerable social groups is neglected.

Arguing that social sciences should supplant medical ones would, however, be the worst kind of backward thinking. More multidisciplinary research and policy analysis are needed. At present a major bias exists in research funding. Most of the available resources go into the invention of new technologies even though their aggregate contribution to the population's health is modest. Relatively little effort goes into assessing the effectiveness of the existing health care system, and almost nothing is invested in looking at the non-medical influences on health. What's urgently needed is a more systematic programme of research to improve our understanding of the socioenvironmental determinants of health and of how to design public policies that will prevent or ameliorate poor health.

More generally, debate on health policy in countries such as Britain needs a new perspective. A sustained effort should be made to persuade not only politicians and patients but also those who earn their living in the health care industry that it makes economic and social sense to limit spending on health care to free resources for other policies that promote health. Investing in health remains a worthwhile objective, but it means much more than spending on the NHS.