I start a week of teaching on the social determinants of health on Monday with our 1st year physiotherapy students. It’s part of a course/module we run at AUT called ‘Physiotherapy and Health Priorities’ and it looks at applying public health principles to our practice.
Social determinants aren’t something that physios have spent a lot of time studying in the past, and it’s a bit alarming to see how little research is out there that points to a role for the profession. We’re not even driving the ambulance at the bottom of the cliff on this issue: we’re the people who pick up the patients who have left the ambulance after its already crashed. Clearly this is not a wise or enviable position for a profession to be in with an increasingly ageing, chronically ill population of people who are suffering from a plethora of preventable ‘lifestyle’ disorders.
Social determinants of health are those things that people are born into, or are forced to live with, that adversely affect their health. Poverty and income inequality, unemployment, education, housing, culture and ethnicity, access to services, the physical environment, and personal safety, are just some of the key determinants that have been extensively studied (for a brief summary see, for example Marmot et al, 2008).
A recent study in America suggested that as much as 40% of the impact of health was due to socio-economic influences, with 30% being due to health behaviours like smoking, drinking and lack of exercise, and as little as 20% of the influences on health due clinical services and the quality of care (Maynard, 2014). And while I’m always highly skeptical of such gross statistics it’s not hard to see that social determinants play a huge part in the health of our communities.
In New Zealand – a developed country with a small population and temperate climate – some of the figures are quite startling:
- Nearly 1 in 3 children live in poverty, while just 29,000 people hold 16% of the nation’s private wealth – 3 times more than the lowest 50% of the population (Rashbrooke, 2013).
- The number of poor people in New Zealand has doubled since the 1980s, and the majority of these are women, children, Māori and Pasifika (Rashbrooke, 2013).
- Income inequality in NZ is on a par with Australia, the UK and Portugal, and while not as bad as the USA, shows a strong correlation with health and social problems (see figure below, and also this link to the Health and Social Problems Index).
- A 2012 UNICEF report put New Zealand above only the USA at the bottom of a league table showing the link between poverty and child health (Innocenti Research Centre, 2012).
- Unemployment is an ongoing problem for many disadvantaged people in New Zealand (Waddell & Burton, 2006). (One of the contributors to this report – health consultant Nick Kendall – claimed at a Physiotherapy New Zealand conference a few years ago that long term unemployment had an equivalent effect on one’s health to smoking 10 packs cigarettes per day).
- ‘People who live in deprived areas are more likely to experience poor air quality, high risk water supplies, and low quality housing that has a higher likelihood or being built on a contaminated site. They experience increased hospitalisations, total mortality, injury related mortality, asthma prevalence in adults, sudden infant death syndrome, and mortality due to causes that are potentially preventable by medical treatment’ (Shaw, 2004).
When it comes to discussing these issues with physio students, what is most telling is that they struggle to see themselves even having a role in tackling social determinants. Even in year 1, they don’t see themselves as professionals with a responsibility for community engagement, advocacy or health policy work. Their working life will be spent fixing the problems of the patient that lies immediately under their hands.
The problem, though, is not so much trying to show them that social determinants matter – they can see perfectly well what a devastating impact poverty, pollution and lack of personal safety have on communities – it’s that they don’t think they can do anything about it. And their profession hardly helps.
And so, at the risk of sounding simplistic, there are (at least) five things I try to get them to think about in the hope that they recognize that they’re not impotent, and that it’s not somebody else’s job:
- Firstly, and most basically, don’t make it worse. In New Zealand, almost 60% of the profession is in private practice. Naturally, these practices aggregate in areas where people can afford the cost of care. This decreases access to physiotherapy for those who cannot afford the treatment or the costs of getting there. We could do a lot of good for people on low incomes if we could find a way to provide affordable physiotherapy in communities of need.
- Use social measures for social problems. Everything in health care is about personal responsibility these days. Rose Galvin (2002) has an interesting take on why this is. She says that we have so much health promotion and health information these days because we need to be made responsible for our own health, so that we will be liable for paying for all our care when we get older. She calls this ‘culpability in the face of known risk’. Personal responsibility can be really judgmental at times, and often sounds like victim-blaming. Social determinants require a different response – a response that is about the community – the family – or society at large. Social action doesn’t single people out for blame, but looks at the conditions that make good health possible for all. Action targets the structural societal problems and not the people who suffer from them.
- Enable, don’t fix. Unless you live in the community you are taking action with (and that’s not a bad place to start), you will be an health care worker employed for your expertise who gets to go leave the community you’re working with at the end of the day. So try to enable the people in the affected community to take their own action. Help them analyze what’s going on and use your expertise to help them to make their own decisions.
- Build dependence. It sounds counter-intuitive these days when everyone is supposed to be autonomous and independent – or at most ‘inter-dependent’ – to advocate for dependence, but dependence is the life blood of communities: people relying on each other for help and support. Make connections, bring people together, share resources, etc. Building dependence doesn’t have to be about possessiveness. If you have also helped empower people to take action for themselves they will soon let you know when your expertise is no longer needed.
- Change the economy. Find a way to channel funding to communities of need. If people earn poor wages because of poor quality education, and so have to move to areas where housing is cheaper (assuming they can afford a house), then they are more likely to live in conditions conducive to poor health and limited choices. Find a way to provide the same services in these communities that the ‘worried well’ have come to expect.
Governments all over the developed world are looking for ‘joined-up solutions’ for health problems that have their origins in the social conditions that people are born into and live with despite the choices they might like to make. If physiotherapists focus only on ‘the body to hand’ we will be gradually sidelined in favour of practitioners who can better meet the needs of the community.
I’ll be trying this week to inspire some of our 1st year students to think that their role here involves more than telling people to lose weight, stop smoking and get more exercise. It will be interesting to see if, in the future, they’re ready to take up the challenge.
Galvin, R. (2002). Disturbing Notions of Chronic Illness and Individual Responsibility: Towards a Genealogy of Morals. Health, 6, 107-137.
Marmot, M., Friel, S., Bell, R., Houweling, T.A.J. & Taylor, S. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet, 372, pp. 1661-9.
Maynard, A. (2014). “If you could do one thing…” Nine local actions to reduce health inequalities. Report published by The British Academy, January 2014. Available at http://www.britac.ac.uk/templates/asset-relay.cfm?frmAssetFileID=13320. Accessed 20th August 2014.
Rashbrooke, M. (2013). Why inequality matters. In, M. Rashbrooke, Inequality: A New Zealand Crisis. Wellington, NZ: Bridget Williams Books, pp. 1-17.
Shaw, M. (2004). Housing and Public Health. Annual Review of Public Health, 25, pp. 397-418. DOI: 10.1146/annurev.publhealth.25.101802.123036
UNICEF Innocenti Research Centre, (2012). ‘Measuring Child Poverty:New league tables of child poverty in the world’s rich countries’, Innocenti Report Card 10, UNICEF Innocenti Research Centre, Florence. Available at http://www.unicef-irc.org/publications/pdf/rc10_eng.pdf. Accessed May 15th 2013.
Waddell, G. & Burton, A.K. (2006). Is work good for your health and well-being? Norwich, TSO. Available at http://www.activeohs.com.au/userfiles/hwwb-is-work-good-for-you-exec-summ.pdf. Accessed 10 December 2011.