Physiotherapists don’t generally think our profession is ‘political.’ We mostly work on people’s bodies, in one-to-one sessions, and few of us use our social standing as respected, orthodox health professionals to campaign for community causes. There are no physiotherapy-specific models of population health, and subjects like primary health care and health promotion are only just beginning to appear in undergraduate curricula. So while physiotherapists are experts in the assessing and treating the body-as-machine, and we are increasingly interested in people lived experiences of health and illness, we are less aware of the social determinants of health.
Social determinants are those things that people are born into or live with against their will. These are not the behaviours people exhibit, like smoking, eating poor quality food, playing contact sports, but the things they have little or no choice over. These are things that negatively affect their health and wellbeing: poverty and incomes, housing, education, access to services, environmental pollution, food, social justice, etc.
The evidence is now absolutely clear: the worst health is not the result of bad choices – although this is certainly a factor further down the line – but the result of conditions that people often have little or no control over.
To give an example, a child born into a poorly insulated, cold damp house is significantly more likely to suffer respiratory illness, die prematurely, or suffer from community-acquired illness. Because their family is poor, they will often live in an area where the schooling is less than ideal which compounds the time off taken by the sick child. The child leaves school early and gains few qualifications. This results in a lifetime spent in poor paying, unstable, mostly part time jobs and struggling to make ends meet. The cost of housing in the nice parts of town is prohibitive, so the young family moves to a poorer area where the roads are noisy and polluted, the services are less well connected and the housing stock is poor. They are naturally further from health care services and can’t afford to travel the extra distance to clinic appointments. They consume poor quality food because it’s cheap and available and the most available calories at the lowest cost. Their children are born into poorly insulated, cold damp houses…and so the cycle continues.
These are stereotypes, for sure, and I do not wish to portray everyone who is struggling to make ends meet as the warden of a failed state. There are many admirable stories of people lifting themselves out of poverty, and stories of people surviving really appalling conditions to make good. But these are rare compared with the millions of people who don’t have the luxury of choice.
There is now an enormous body of work showing how important social determinants are. A recent post from the Canadian Medical Association highlighted the role that doctors should play in turning around the effects of social determinants. This pointed to an amazing collection of resources held by the Institute of Health Equity in the UK, under the leadership of Sir Michael Marmot – probably the world’s leading authority on social determinants. (Navigate to the Presentations and Articles sections for downloadable resources).
The question remains though, what should we do?
Firstly, we should be more aware of the problem of social determinants. For some years I’ve taught this subject to physiotherapy students at AUT, and you can find a link to an introductory lecture I do here. You’re free to use this in whatever way you want. There are many other freely available resources on the internet too should you want to be more familiar with the arguments or the evidence – see the bottom of this post for some more useful resources.
Then we should consider how we can use our professional status to fight the causes of ill health in our communities. Too much time is being spent on telling people to lose weight and get more exercise. These may be important things to say, but they stigmatise people and encourage lazy, victim-blaming attitudes instead of looking at the root causes of poor health. (What’s more, you don’t need a three or four year degree to tell someone to try stop smoking.) We should be looking further than this; going beyond the rhetoric to more insightful interventions.
As Helen Kelleher and Colin McDougall say in their excellent book Understanding Health, ‘One of the problems with contemporary health care is that it focuses on ‘soft target’ risk factors ‘such as physical activity, nutrition and weight control that target individuals rather than environments and structural conditions that in turn, are causal pathways for heart disease, diabetes and cancer’ (Keleher & MacDougall, 2009, p. 28).
Physiotherapy could make a really significant contribution to social determinants of health, but we will need to move a lot away from our individualistic approach if we are to make the changes that millions of people are calling out for.
Kelleher, H. & MacDougall, C. (2009). Understanding health: A determinants approach. South Melbourne, Oxford University Press.
Other useful resources