The way the initial question is posed makes me wonder if you thought that social determinants of health are supposed to explain all vulnerability to disease or all the factors needed for being healthy. The first three responses to the question all indicate that developing disease or staying healthy has multiple types of determinants. And, indeed, these can interact. Take a very simple disease such as influenza which right now is occurring in many parts of the world. The immediate cause of the disease is infection by the influenza virus. The virus potentially can infect anyone who does not have sufficient antibody to the particular strain of the virus that is "in circulation." But, the likelihood of exposure to the virus depends on the likelihood of contact with someone who is infectious. That, in turn, can be affected by the local population density - such as the number of persons who share a household. The severity of the disease can be affected by other factors such as poor nutritional status. So, even in this simple example there are multiple types of determinants of health and disease and severity, or impact, of disease.

It is also worth remembering that disease and health are not just physical states but also emotional states. There are factors that affect mental health. Furthermore, mental health and physical health can interact.

All this is well-known; and yet, I do not believe that anyone can state that we know exhaustively all the factors or possibly even the types of factors that can affect health and disease.

No. We have not even scratched the surface for vulnerability, risk, or etiologies for most chronic diseases. We know that the immune system responds well to positive thinking, happiness, having purpose and value in life, having good interpersonal relationships....all of these areas offer vast new frontiers of discover. All of these, too, present new and remarkable challenges for new methodologies, new ways to measure everything from beliefs to cell physiology....we have much to do.

Science is unlimited by human thinking. A given health status is a product of complex interaction of complex list of determinants. The theory of social determinants of health is not exhausted yet. Health and disease is a dynamic process which is not only determined by biological or physical or chemical or social factors. It is much beyond such simplicity.

The way the initial question is posed makes me wonder if you thought that social determinants of health are supposed to explain all vulnerability to disease or all the factors needed for being healthy. The first three responses to the question all indicate that developing disease or staying healthy has multiple types of determinants. And, indeed, these can interact. Take a very simple disease such as influenza which right now is occurring in many parts of the world. The immediate cause of the disease is infection by the influenza virus. The virus potentially can infect anyone who does not have sufficient antibody to the particular strain of the virus that is "in circulation." But, the likelihood of exposure to the virus depends on the likelihood of contact with someone who is infectious. That, in turn, can be affected by the local population density - such as the number of persons who share a household. The severity of the disease can be affected by other factors such as poor nutritional status. So, even in this simple example there are multiple types of determinants of health and disease and severity, or impact, of disease.

It is also worth remembering that disease and health are not just physical states but also emotional states. There are factors that affect mental health. Furthermore, mental health and physical health can interact.

All this is well-known; and yet, I do not believe that anyone can state that we know exhaustively all the factors or possibly even the types of factors that can affect health and disease.

Dear Jeadran:

You can read : Addressing the social determinants of health in young people.

The Lancet volume 387, Nº 10024, p 1134, 19 March 2016

Best wishes.

Diana from Perú.

I’m not sure the theory of social determinants of health has been exhausted. However I do wonder if the limitations are rooted in the tendency to confuse correlaction with cause. There are lots of social indicators correlated with health outcomes but it is less clear about the causal relationships between these indicators and specific health outcomes.

Underlying the social determinants of health are setting-dependent structural factors (among others) that variably influence causality in health.

Pan American Health Organisation studies have concluded that these structural factors operate through hierarchies of power, prestige and access to resources.

These influences permeate societal, social, familial and inter-personal spaces and change the way we ought to think about social, behavioural and other health determinants.

I suspect that we are only at the beginning of this discourse, as earlier respondents have also noted.

Alan you make some important points identifying some interesting research that support the social determinants theory. However given what you say I'm not sure this PAHO research does more than identify correlates rather than causal explanations. It sounds like what the PAHO research asserts is that local power structures is a missing variable that is correlated with health outcomes and social indicators. This could mean that the link between social indicators that comprise most social determinant models and health outcomes may be a spurious relationship. It may then mean that local power structures are the primary influencer of health outcomes, but what does that mean? How would that work? For example, do local elites limit access to or completely withhold treatment from non-elites? Do elites limit or restrict health care resources?

Hi John - thanks for your response. You make very good points around association and causality, with which completely I agree. I was quoting PAHO and their use of 'causality' to highlight the point about power issues. But you have raised specific questions around the operation of power in shaping health determinants.

Certainly in the health systems space in my national context, power over policy and the distribution of resources resides centrally (at least at provincial level) and expenditure priorities tend to concentrate in metropolitan-based services . It is not so much a question of health system elites deliberately limiting access to resources by more peripheral (i.e. regional, rural and remote) health service agencies. Rather, i think that there is a generally poor understanding by those with power to make policy and financing decisions of the flow-on effects of those decisions for health outcomes of rural living peoples, peoples who more often have less capacity to apply political pressure to address the issues, at least in my national context.

I think that developing a clearer picture of the association between power relations and the profiles of health determinants will help further develop the discourse. No doubt the debate will continue...

Very interesting Alan! Thanks for sharing your thoughts!

Thank you very much everyone for sharing your points of view. For the sake of continuing the discussion I would like to touch on a point that I consider central. From the paradigm of the social determinants of health there is a deterministic spirit of health and disease outcomes. In this sense, the approach raises explanations from the dimension of the dimension of the known, where the causes are identifiable and the effects are repeatable, perceptible and potentially predictable.

However, from my point of view, health and often disease, are a problem "not compressible and undecidable" which is, at least in part, in the domain of uncertainty. In this sense, the uncertainty that is omnipresent in the system raises the impossibility of predicting and controlling modellers that affect the health and disease process.

On the other hand, the place occupied by the cultural determinants of health and disease in the paradigm of the determinants of health is insufficient. This way of seeing leaves out an aspect of vital importance: both, health and disease are social constructions. And this has a great relevance at a population level. The culture is not just another determinant, but a modeller that crosses the entire system and expresses itself in different ways.

What I am trying to illustrate is that the health - disease phenomenon is not sufficiently well explained from the paradigm of the social determinants of health. And this have an impact not only on the interpretation of the problem, but on the approach. I consider this way that it is necessary to look for more flexible models that allow to give an account of what happens inside the system, to obtain better results in health.

The Harvard Health and Human Rights Journal is calling for papers for an upcoming Special Section: Deepening the Relationship between Human Rights and the Social Determinants of Health: A Focus on Indivisibility and Power (please see: https://www.hhrjournal.org/submissions/call-for-submissions-upcoming-issues/). Some of the interesting discussion emerging here would make for great papers in this Special Section.

Thought I'd flag!

Sometimes going from macro- to micro- can help focus the discussion. For instance, within the cancer patient & caregiver communities there are continuous concerns about uncertainty of diagnosis, treatment, prognosis and etiology. Blaming the victims is common for lung cancer patients...including those who never had toxic exposures. But the uncertainty of it all affects people dealing with cancer and cancer-care. The uncertainty clearly increases levels of anxiety, depression, exhaustion, and these must have effects on the immune system's performance.

Cancer, for instance, presents a very obscure clinical picture and dealing with it, within a social construct, could be compared to a class such as vascular disease with more clinical clarity.

In some communities having cancer becomes a social isolating factor; uninformed people fear "cancer" and respond even as if it is communicable. Such responses are far less common with cardiovascular disease and many other chronic conditions. Bringing the discussion "home" such as this might bridge the purely theoretical with the epidemiological and clinical....we need such bridges.

Appreciate the question and the answers so far.

No I do not believe we have. We know that as long as 45 million Americans remain at or below the poverty line and close to one-third of all households make below $35,000 (net), we have a social context that does not allow for equal success to the means for that will allows us to be healthy. We have a political context that is increasingly less support of legislation designed to provide support for all of us to have this access, such as the annual raiding of the Prevention Fund.

Remember the theory alone does not fully explain the differences we see, because of both the biological, historical, economic and social roots are multi-factorial, yet proposed solutions are generally singular, such as a focus on a particular disease or health insurance payment program, or on a single institution, such as access to a hospital or clinic. What this means is that the use of the theory often ends at the point of application to actionable recommendations and similar efforts, as well as to the development, testing and implementation of evidence-based practices and interventions.

The point is, the latter take into account the fact that individuals, even those with chronic conditions, encounter actual medical care delivery systems lees that 10% of their lives, while they live in economic, social and physical environments that psychologically and culturally influence the beliefs, behaviors and resources we know effect health outcomes.

Simply put, the theory only partially explains what we know. As made clear by others, we need more robust models that are not only more ecological, but are more intervention/outcome oriented as well.

Hope this helps.

Saludos a todos

I am currently investigating the abandonment of hospital therapy and readmission of children facing malnutrition in Oaxaca, Mexico. While the social determinants ' proposal allowed us to identify vulnerable groups, how anthropologists limited us to identify sociocultural factors that turn out to be key in the configuration of health services and hospitals. So in regions where apparently they had all the services and means; an administrative and inoperative bureaucracy was found that hinders and saturates the work of health professionals. For example, the so-called Burnout syndrome, in Oaxaca, is related to other aspects with constant budgetary cuts and diversions of resources in the health sector and adverse working conditions.

In another investigation when working the patient medical communication in public clinics of family medicine. We find the predominance of the administrative agenda in the procedures, times and spaces of the clinic.

http://www.manualmoderno.com/tienda/index.php/medicina/9786074486759.html

I appreciate Lifeworld-led practices as they lead with the subjective experience of the individual. This allows for the social determinants of health to authentically relate to the individuality of each person‘s circumstances in life. This method is also guided by the belief that we are the experts of our own life and give way for professionals to walk alongside their patients versus over them. I feel when we are open to the unique perspective of others, we can more accuratly provide holistically-minded care.

The short answer , in my view, is no, we haven't. Certainly more factors and mechanisms can be added to our current understanding of how social conditions affect health. For example, relatively new work in epigenomics opens another pathway for understanding how social factors can cause inheritable changes in genes. We're not at the end yet.

I could add a great quote from Neil DeGrasse Tyson's book Astrophysics for People in Hurry: "When first proposed, most scientific models are only half baked, leaving wiggle room to adjust parameters for a better fit to the known universe."

The basic theory that broadly describes the social determinants of health is that your health is determined by three factors: Who you are (including your genetic inheritances); Where you live (including all of your environments since you were an egg and a sperm) and How you live ( including your relationships, health behaviours etc.). Lots of wiggle room.

Another way to look at social determinants of health is to include the healthcare provider's trait/state contribution to healing or lack thereof. Whether the healthcare worker is "overworked", suffers of burnout, has too many patients, sees no way they can help the patient in his/her social context or is devoid of empathy must also be taken into account ...

Adriana makes a good point. Researchers in the health determinants field tend to regard the formal health/medical system and its providers as less important than non-medical factors, when you are interested in what contributes fundamentally to population health,

For a more detailed review of this issue, see my presentation under Contributions: Society and Health: The Contributions of Medical Care to Life Expectancy and Well-Being.

From a public health perspective it is clear that "health care" or health sciences is fully invested in interventional medicine. For most people, most of the time, medical encounters only emerge when health is challenged by injury, disease, or an insidious pathology. Most Health status is determined by nutrition, shelter, quality of life, meaningful purpose for living, trusted and trusting human relationships, and the wild cards of genetics and the "accident of birth" where some people are born into advantages while many others are born into marginal economic and social status that will largely determine their lifetime of opportunity and barriers to opportunity.

Dear @DavidMortonLow and @RichardLDouglass

You mentioned an interesting and controversial point. The Social Determinants of Health are explained by three factors: who you are, where you live and how you lived.

From my point of view, that is the problematic core of the problem. I would like to start by mentioning that living systems are not linear; There is no rule that says an exhibition has an effect. In this sense, most of the results on the health and illness phenomena are stochastic, not deterministic.

On the other hand, the outcome of the disease health process is more than the sum of its determinants. Sometimes what helps someone hurt the other or exposure to a substance can affect some people and not others. From the SDH view the general practice has been to write determinants interaction into the general linear model and ignore the complexity that they indicate. Sometimes, the additive effects of multiple variables (or determinants) are not additive.

In this way, the understanding of the health and disease phenomenon seem to require new approaches, perhaps contrary to the intuitive logic of the model of social determinants of health that allow us to advance in the design of more and better health interventions.

Jeadran’s comments are really on point.

Yes, Jeadran, it is not linear. One of the consequences of social sciences moving forward conceptually and methodologically is that most of us were initially trained in a linear, stochastic, analysis model world.... living long and testing theoretical models in the real world has humbling implications for us; we might be able to publish with a 60% confidence....but that leaves 40% to non-linear, random notions about which we know little or nothing. This complexity in the real world must be the clarion call for emerging scientists and theoreticians if our work is to contribute to the emergence of a better, more sane, and more nurturing life for everyone. It will require new research methods, new and more complicated and multi-disciplinary models, and an end to silo-thinking among academics within their own disciplines. This forum represents the kind of discussion platform that we all might have used 25 years ago...think about the new ideas and partnerships that could have emerged!

Thanks Jeadran .... the world is getting smaller.

In social epidemiology, concepts of health and the factors that influence health at 'population' levels are framed within complex social and ecological systems. In population health practice, the evidence has been long established that any efforts to address local burden of disease require multi-strategic, multi-level (e.g policy, social, fiscal, health systems), multi-year approaches. Linearity has never been a guiding principle in this praxis!