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 Two Conceptual Challenges for Public Health Equity Champions:

Understanding Structural Vs. Intermediary Determinants of Health, and Power

   Source of selected quotes and two figures: Solar, O., & Irwin, A. (2010). A CONCEPTUAL FRAMEWORK FOR ACTION ON THE SOCIAL DETERMINANTS OF HEALTH social determinants of health discussion paper 2 (policy and practice) Accessed January 21, 2015 at www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf      

(Figure  page  6)      …conflating  the  social  determinants  of  health  and  the  social  processes  that  shape  these  determinants’  unequal  distribution  can  seriously  mislead  policy.  (page  5  emphasis  added)    The  role  of  social  position  in  generating  health  inequities  necessitates  a  central  role  for  a  further  two  conceptual  clarifications.  First,  the  central  role  of  power….The  central  role  of  power  in  the  understanding  of  social  pathways  and  mechanisms  means  that  tackling  the  social  determinants  of  health  inequities  is  a  political  process  that  engages  both  the  agency  of  disadvantaged  communities  and  the  responsibility  of  the  state.  (page  5,  emphasis  added)      

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Second,  it  is  important  to  clarify  the  conceptual  and  practical  distinction  between  the  social  causes  of  health  and  the  social  factors  determining  the  distribution  of  these  causes  between  more  and  less  advantaged  groups.  The  CSDH  [the  World  Health  Organization  Commission  on  the  Social  Determinants  of  Health]  framework  makes  a  point  of  making  clear  this  distinction.  (page  5  emphasis  added)    The  most  important  structural  stratifiers  and  their  proxy  indicators  include:  Income,  Education,  Occupation,  Social  Class,  Gender,  Race/ethnicity  (page  6  emphasis  added)      The  vocabulary  of  “structural  determinants”  and  “intermediary  determinants”  underscores  the  causal  priority  of  the  structural  factors.  (page  6  emphasis  added)    The  CSDH  framework  departs  from  many  previous  models  by  conceptualizing  the  health  system  itself  as  a  social  determinant  of  health  (SDH).  The  role  of  the  health  system  becomes  particularly  relevant  through  the  issue  of  access,  which  incorporates  differences  in  exposure  and  vulnerability,  and  through  intersectoral  action  led  from  within  the  health  sector.  The  health  system  plays  an  important  role  in  mediating  the  differential  consequences  of  illness  in  people’s  lives.  (page  6  emphasis  added)    …the  political  nature  of  the  endeavour  needs  to  be  an  explicit  part  of  any  strategy  to  tackle  the  SDH.  (page  7  emphasis  added)        

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(highlight  added,  Figure  page  8)    Arguably  the  single  most  significant  lesson  of  the  CSDH  conceptual  framework  is  that  interventions  and  policies  to  reduce  health  inequities  must  not  limit  themselves  to  intermediary  determinants,  but  must  include  policies  specifically  crafted  to  tackle  the  social  mechanisms  that  systematically  produce  an  inequitable  distribution  of  the  determinants  of  health  among  population  groups  (see  Figure  B).  To  tackle  structural,  as  well  as  intermediary,  determinants  requires  intersectoral  policy  approaches.  (page  7  emphasis  added)    Prepared  by  Jim  Bloyd,  MPH  Cook  County  Department  of  Public  Health  jbloyd@cookcountyhhs.org  (708)  633-­‐8314    Submitted  January  21,  2015  to  the  Region  V  HRSA  Collaborative  Improvement  and  Innovation  Network  to  Reduce  Infant  Mortality  (ColIN),  and  the  Illinois  Department  of  Public  Health  ColIN  Illinois  Social  Determinants  of  Health  Committee