Determinants of Health

Regilda Garcia
1910070100014
 Introduction to determinants of health

The determinants of health are classically categorized into behavioural factors,

impacts of the natural environment, genetic determinants, and social determinants,
but these overarching categories mask the complexity and diversity of, and
interaction between, the drivers of health and disease. These fundamental
determinants have acted, and interacted, within populations incomplex ways
throughout history. For example, the European conquest of the Americas in the
sixteenth century decimated native American populations not just through
subjugation (social determinants), but also through land confiscation and
associated food insecurity (social and environmental determinants), and the spread
of infectious diseases— smallpox, measles and plague among them—that
Europeans had developed moderate resistance to over generations (biological
determinants)
Complicating
features of
determinants
Dynamism

The determinants of health are complicated by their dynamism. The common

practice of expressing the relationship between exposure and disease as a relative
risk does little to convey the complexities of the temporal relationship between
exposure and disease. An abrupt change in exposure, for instance, may not lead to
a sudden change in the associated disease response. Time lags between exposure
and disease, or disease responses for which cumulative exposures are required,
have posed significant challenges to improving our understanding of important
health risks, such as indoor air pollution and cancer risk assessment. Health-
damaging exposures themselves have complex temporal characteristics, with
specific time-scales relevant to particular health outcomes—i.e. cumulative long-
term levels are most relevant to some exposures, peak levels most relevant to
others.
Multi-scale

The determinants of health are not only dynamic and changing, they operate at
various scales. Persons who are charged with promoting health—both directly and
indirectly—typically operate at the scale of their training. Physicians and nurses
work at a personal scale, hospital administrators and health product manufacturers
at a more derivative scale, ministers of health at a focused governance level, and at
the top level, elected (or arrogating) officials develop and execute military,
industrial, agricultural or other policies with sweeping and sometimes global
consequences for health. Indeed, at this level national and international leaders
frequently make decisions that have great influence on health with limited
awareness or consideration of impacts on health. It is the role of health officials to
assure that political and institutional leaders at all levels understand health
determinants, which themselves span a wide range of scales and domains.
Solutions to interconnected challenges, for example, prevention of waste or
contamination of drinking water, can offer benefits across not just health domains,
but benefits for food and industrial production, cost, and environmental savings.
Cross-boundary

Many key public health threats pose risks that transcend international borders,
such as risks resulting from mobile atmospheric or aquatic environmental
pollutants, and those that stem from global socioeconomic integration (e.g.
increases in global air transport trade, and migration). In the former category, air
pollutants, for instance, are transported internationally and intercontinentally and
the consequences for public health thus extend far from the site of emissions. Dust
from sources in Asia traverses the Pacific and has reached surface locations in the
United States in a matter of days and mercury emitted mainly from coal
combustion remains in the atmosphere for about a year and poses a serious cross-
boundary threat. Likewise, greenhouse gases (e.g. carbon dioxide and methane)
lead to global climate change no matter where emissions occur, and thus the health
and economic consequences, such as loss of life and property resulting from
increased frequency of extreme temperature events, are widely dispersed across
national and continental boundaries.
State-changes

Large, abrupt changes at societal or planetary levels can drive patterns of health
and illness, often for generations. Conflicts between nation states often originate
from resource competition, although camouflaged as moral, religious, or ethnic dis-
putes, and can affect health not just for years but for generations. Wars fought over
land and water rights, for instance, can exact heavy and rapid health and economic
tolls,and can arise even among seemingly similar religious or ethnic groups, such as
Protestants and Catholics in Europe, or the Tutsi and Hutus in Africa. National
conflicts can cause abrupt tears in the social fabric, including scores of civilian
casualties, the loss of homes and community support systems, sudden depletion or
loss of food, water, and other essential resources, and large, rapid unplanned
migrations of populations under dangerous conditions. Mental health
consequences invariably accompany these abrupt changes to systems that support
health, and when a new stable state is achieved, it can often be far inferior in its
support of population health, such as the establishment of long-term refugee
camps, forced repatriation, or loss of nationhood accompanied by ongoing social
unrest.
State-changes

Large, abrupt changes at societal or planetary levels can drive patterns of health
and illness, often for generations. Conflicts between nation states often originate
from resource competition, although camouflaged as moral, religious, or ethnic dis-
putes, and can affect health not just for years but for generations. Wars fought over
land and water rights, for instance, can exact heavy and rapid health and economic
tolls,and can arise even among seemingly similar religious or ethnic groups, such as
Protestants and Catholics in Europe, or the Tutsi and Hutus in Africa. National
conflicts can cause abrupt tears in the social fabric, including scores of civilian
casualties, the loss of homes and community support systems, sudden depletion or
loss of food, water, and other essential resources, and large, rapid unplanned
migrations of populations under dangerous conditions. Mental health
consequences invariably accompany these abrupt changes to systems that support
health, and when a new stable state is achieved, it can often be far inferior in its
support of population health, such as the establishment of long-term refugee
camps, forced repatriation, or loss of nationhood accompanied by ongoing social
unrest.
Examples of determinants
exhibiting such complexity
Interactions between migration, healthcare delivery,
and immunization: an example in China

A range of determinants illustrates the complications described earlier, and among

them global urbanization serves as an especially illuminating example. Urbanization
is proceeding at rapid pace globally, presenting substantial health risks, such as the
challenges of meeting the healthcare needs of large, migrating populations.
Urbanization impacts health through complex and multifactorial pathways,
involving a number of the complications already described. In China, for instance,
the health risks of urbanization are not borne equally: the major healthcare delivery
challenges that arise from rapid rural-to-urban migration have diverse impacts on
migrant populations. Provision of childhood immunization services to the children
of migrants, for example,has been significantly complicated by urbanization.
Interactions between determinants of infectious
disease and of non-communicable chronic disease

Another key example where the determinants of health are interacting in novel
ways is the convergence of non-communicable disease (NCD) and infectious
disease (ID) in LMICs a convergence that existing health systems and public health
approaches must grapple with. Prevention and control programmes for NCDs like
cardiovascular disease and diabetes mellitus and IDs such as TB, HIV/AIDS, and
certain parasitic diseases rarely interact, even though NCDs and IDs share
important common features. There are common risk factors for NCDs and IDs, and
key interactions between NCDs and IDs lead some individuals with NCDs to be
more susceptible to IDs. For example, diabetes increases susceptibility to various
communicable diseases, such as TB and malaria. As a result, LMICs are
experiencing a large, simultaneous burden of disease from NCDs and IDs
Environmental health versus economic development
and inequality

Historically, the early stages of national economic development begin with resource
extraction and resource-rich developing countries are often courted by industrial
countries and their multinationals for access to their raw materials, along with their
inexpensive labour, weak environmental regulations, and sites for hazardous waste
disposal. These industries can generate rapid wealth, and the political and financial
conditions that accompany extraction economies run the risk of becoming
repressive toward labour rights, and indifferent and hostile to environmental
protections. industries are often subject to ‘boom and bust’ cycles, which can be
detrimental to social stability and health. Maintaining good governance in the face
of an influx of new wealth, generated by a small number of industrial agents, can be
challenging, and political processes have been observed to be manipulated by
vested interests. Weak governance during boom bust cycles can render public
services such as schools, transportation, and healthcare ineffective and at times
non-existent.
Ageing and urbanization

Ageing and urbanization are occurring simultaneously in many settings, raising

unique public health challenges and illustrating the dynamic, multi-scale nature of
the global determinants of health. China, for instance, is experiencing a
demographic age shift as a result of declining fertility and increasing life
expectancies.
Health risks and benefits of urbanization

No major social, environmental, or behavioural change is without health impacts,

both positive and negative, and examining the benefits, alongside health risks, is
essential. Returning to urbanization, the phenomenon in LMICs is frequently
characterized as essential to future prosperity, while at the same time a threat to
health and, in the case of unplanned urban expansion and sprawl, harmful to local
and global environmental quality. Globally, migrant flows are continuing into cities
at a rapid pace, and important adverse health effects that have long been
associated with living in urban areas have been extensively reviewed.