Limited Awareness of the Social Determinants of
Health in U.S. Public Health Policy
SHAPING PUBLIC POLICY AND POPULATION HEALTH
IN THE UNITED STATES: WHY IS THE PUBLIC
HEALTH COMMUNITY MISSING IN ACTION?
Dennis Raphael
Renewed international interest in the structural determinants of health manifests itself in a focus on the social determinants of health and the public policy
antecedents that shape their quality. This increased international interest
in public policy in support of the structural determinants of health has had
little traction in the United States. This should be surprising since the United
States presents one of the worst population health profiles and public policy
environments in support of health among wealthy developed nations. The
U.S. position as a health status and policy outlier results from long-term
institutional changes that are shaped by political, economic, and social
forces. U.S. public health researchers’ and workers’ neglect of these structural and public policy issues conforms to the dominant ideological discourses that serve to justify these changes. The author presents some
means by which public health researchers and workers can challenge these
dominant discourses.
The reality that living conditions are the primary determinants of health was
first brought to public and professional attention by the extensive writings of
Rudolf Virchow and Friedrich Engels that began in the 1850s (1, 2). More
recently, international interest in the social determinants of health represents
another cycle of recognition of the importance of structural determinants of health
that began in the 1980s with the publication of the Black and Health Divide reports
in the United Kingdom, numerous World Health Organization declarations on
the prerequisites of health, and the current WHO Commission on the Social
Determinants of Health.
International Journal of Health Services, Volume 38, Number 1, Pages 63–94, 2008
© 2008, Baywood Publishing Co., Inc.
doi: 10.2190/HS.38.1.d
http://baywood.com
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A variety of social-determinants-of-health shopping lists are available, but
what they all share is a concern with how living conditions—rather than biomedical and behavioral risk factors—shape health. Considering the United States’
rather bleak population health profile and profoundly problematic approach
to public policy, it would be expected that U.S. public health researchers and
workers would show a lively interest in analyzing—drawing upon just one
such list of living conditions that shape health—how early life, education, employment and working conditions, food security, health care services, housing, income
and its distribution, the social safety net, social exclusion, and unemployment
and employment security determine population health and health inequalities
(3). Included in such analysis would be a consideration of how the public policy
environment shapes the quality of these social determinants of health (4). Such
a focus is common among many public health researchers and workers outside
the United States, but recent waves of concern with structural determinants
of health appear to have bypassed the mainstream American public health
community (5–8).
It is surprising that there is little U.S. interest in structural determinants of
health and their public policy antecedents, as the United States presents one of
the worst population health profiles and one of the least developed public policy
environments in support of health among wealthy developed nations (9, 10).
Much of this has to do with the neoliberal and neoconservative resurgence that
began in earnest during the Reagan presidency, which coincided—and was
incompatible—with growing international interest in structural approaches to
health promotion (11–13). Now, 25 years after the Reagan Revolution led to
striking increases in income and wealth inequality, dismantling of much of the
U.S. welfare state, and hardening of public attitudes toward the government’s
role in service provision, the U.S. public health community is taking only
cautious steps toward addressing the structural antecedents of health (14, 15).
And even these steps fall profoundly short of the systematic efforts required to
shift public health discourse and activity toward addressing these key issues.
What are some of the reasons for this neglect and what roles could the public
health community play in this effort?
PROVIDING A CONTEXT
This article provides a comparative analysis of the U.S. population health and
public policy profiles with the aim of identifying potential public health activities
in support of health and the barriers that make such efforts difficult. These
issues have not been completely neglected (16–19). But clearly these writings
have been seriously marginalized in public health discourse in the United States,
a point recognized by the same writers that have raised these issues (5, 8). Two
literatures provide the evidence to show that the United States—despite being
one of the world’s wealthiest nations—presents one of the worst population health
Shaping Public Policy and Population Health
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and public policy profiles among wealthy industrialized nations and provide
a context for understanding the ideological barriers that make consideration of,
and action upon, these issues difficult.
The social epidemiological literature explicates some of the social determinants of health that shape population health profiles. While drawing attention
to these issues, much of this work is strangely depoliticized, a reflection of the
epistemology associated with epidemiology’s commitment to positivist assumptions (7). This literature hesitates to consider the obvious: that profound inequities
in health and their precursors, living conditions, are a result of differences in
power, influence, and wealth associated with the operation of the economic and
political system. These issues are relevant to most developed nations but are
especially important in the United States.
In contrast, the political economy literature identifies the political, economic,
and social forces that determine the quality of these social determinants of health.
Yet this important work has had little penetration into, and even less impact
upon, public health activities in the United States. Examples from the social
epidemiology literature provide a context for exploration of the U.S. population
health and public policy profiles. The political economy literature—applied in
later sections—helps explain the distinctive U.S. profile and suggests appropriate
public health responses.
ILLUSTRATIVE SOCIAL EPIDEMIOLOGICAL WORK
The U.S. population health profile and the extent of health inequalities are
illuminated by a comparative social epidemiological framework. The U.S. latemiddle-aged population was recently found to be less healthy—at every level
of income and education—than its English counterparts for self-reported prevalence of diabetes, hypertension, myocardial infarction, stroke, lung disease, and
cancers (20). National differences were robust, remaining after a standard set
of behavioral risk factors—smoking, overweight, obesity, and alcohol use—were
controlled for.
Strong income- and education-related health gradients were seen within each
nation, and the authors suggested their source was the social determinants of
health: “Much evidence points to the social determinants of health—the circumstances in which people live and work—as explanations for social gradients in
health” (20, p. 2044). Concerning differences between nations, they suggested:
“To a much greater extent England has set up programs whose goal is to isolate
individuals from the economic consequences of poor health in terms of medical
expenditures and especially earnings and wealth reductions” (p. 2044).
A comparison of Americans with Canadians found no differences between the
affluent (top income quintile) in self-reported health, severe mobility limitations,
and unmet health care needs (21). But there were striking differences between
the poorest 20 percent of Americans and Canadians. Lower-income Americans
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were more likely to report poor or fair health, a severe mobility limitation, and
having an unmet health care need than lower-income Canadians. No reasons were
advanced for these findings by the authors, and there was certainly no discussion
of the economic, political, and social forces that shape these findings.
Siddiqi and Hertzman (22) linked population health profiles to political and
economic environments by exploring how long-term institutional changes in the
United States and Canada were related to health gaps between these two nations.
Macro-level issues explored included fluctuations of national income and patterns
of distribution, and public policies that shape distribution such as income supports,
education policies, health care organization and spending, and labor regulation,
among others.
In 1960, U.S. infant mortality rates were 2 per 1,000 live births lower than the
rates in Canada. By the late 1990s, a reversal occurred such that Canada enjoyed
a 2 per 1,000 advantage. Mortality rates have consistently favored Canada from
the 1960s to the present. Life expectancies were similar in 1950, but by the 1960s
Canadians lived two years longer.
These findings are explained in terms of broad institutional changes in national
public policies. In the 1970s, the Gini index for income inequality—post tax and
transfers—was three points more egalitarian in Canada. The index value has
remained unchanged in Canada, but by the 1980s had increased in the United
States to produce a five-point gap. By the late 1990s, the gap had increased to
seven points. In 1980, public expenditures consumed about 13 percent of GDP
(gross domestic product) in both nations, but by 1990 a gap had opened such
that Canada was now spending more than 18 percent of GDP and the United
States slightly more than 14 percent. Education spending in Canada increased
to 7 percent of GDP during the 1990s, while the U.S. level was 5 percent. The
authors conclude: “The period during which Canadian life expectancy increasingly surpassed the USA was a time when Canada’s level of public spending
on social programs, the redistributive work of its social safety net, levels of
maintained income equity, and levels of access to education were all surpassing
the USA” (22, p. 599).
Again, there is no discussion of the economic, political, and social conditions
that shape these developments. These studies are consistent with other comparative studies in the social epidemiological tradition in that they are depoliticized and adhere to traditional assumptions concerning the nature of the positivist
paradigm of health sciences research: avoid normative assumptions, bypass
structural analysis of the source of health inequalities, and restrict analysis to the
observable and concrete.
Nevertheless, these studies suggest that the U.S. population health profile
reflects the quality of a variety of social determinants of health related to institutional approaches to social provision and protection. The exact nature of these
differences and how they shape the social determinants of health constitute the
content of the following sections.
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SOCIAL DETERMINANTS OF HEALTH
Renewed focus on social determinants of health, as exemplified by numerous
volumes on the topic (3, 23) and various international (24), national (14, 15),
and regional initiatives (25, 26), can be traced to U.K. researchers’ efforts to
identify the specific exposures by which members of different socioeconomic
groups come to experience varying degrees of health (13). The social determinants
concept struck a responsive chord in many nations where increases in income
and wealth inequalities and cuts to the social safety net were identified as causes
for concern (27, 28).
Concern with social determinants of health led to a focus on matters of
social class, occupational status, and income as key issues that interact with
public policy approaches to shape the nature of inequalities in health and overall
population health (27, 29, 30). These variables represent the means by which
social stratification interacts with public policy to produce differential exposures
to societal resources that shape health (31, 32). The materialist analysis sees the
origin of health inequalities as differences in living conditions (33–35). The
neomaterialist viewpoint takes these issues into account but adds analysis of
societal investments in social infrastructure in support of health (34, 36, 37).
The social-determinants-of-health concept failed to gain much traction in the
United States despite the unparalleled growth in income and wealth inequalities
that took place since the 1980s (10). Instead, issues of social class, occupational
position, and income took a back seat to analysis of racial and ethnic health
disparities, access to health care, and behavioral risk factors (38, 39).
There has been sporadic mention of the social determinants concept in mainstream U.S. academic articles. But the analyses of the public policy antecedents of
the social determinants of health are undeveloped and strangely depoliticized
(40–42). The magnitude of the population health and health inequalities problems
is minimized, limitations and intractable barriers to progressive approaches to
public health are taken as a given, and critical analyses of economic, political, and
social forces working against health are rare. The journal Health Affairs is the
best repository of these limited and rather despondent types of analysis.
THE U.S. POPULATION HEALTH PROFILE
Social determinants of health and their public policy antecedents are especially
relevant to the United States as its health profile is poor in relation to other
wealthy industrialized nations. The Organization for Economic Cooperation and
Development (OECD) produces ongoing comparative analyses of a variety of
social indicators that invariably place the United States in a rather poor light.
The following provides a snapshot of the significant issues located within the
U.S. population health and public policy situation. For the following indicators of
population health, the rank of 1 is the best, with increasing rank number indicating
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poorer relative performance among the wealthy industrialized member nations
of the OECD.
Life Expectancy
The most recent data are from 2002 (9). Life expectancy for American males
was 74.4 years, and for women 79.8 years, providing a relative rank of 22nd
of 30 wealthy developed nations for men, and 25th of 30 for women. The
average life expectancy increase in the United States of 7.2 years from 1960
to 2002 was well below the OECD average of 9.2 years, giving a relative rank of
22nd of 30 nations.
Infant Mortality Rate
Infant mortality rates for OECD countries are available for 2002 (9). Infant
mortality rate is frequently seen as the single best indicator of overall population
health. The U.S. rate of 6.8 per 1,000 gives it a rank of 25th of the 29 wealthy
industrialized nations for which these data were available.
Low Birthweight Rate
Low birthweight rate (<2,500 grams) is important as it is associated with a wide
range of health problems across the life span. In 2003 the U.S. low birthweight
rate was 7.9 per 100 newborns, giving the United States a ranking of 25th of the
28 wealthy industrialized nations for which data were available (9).
Childhood Death by Injury Rate
During the period 1991–1995, 14.1 American children per 100,000 died from
injuries (43). The U.S. rate gives it a ranking of 23rd of 26 wealthy industrialized nations.
Child Maltreatment Deaths
During the 1990s the incidence of childhood death by maltreatment per 100,000
children in the United States was 2.2 per 100,000 (44). This gives the United
States an overall rank of 26th of 27 wealthy industrialized nations. A slightly
modified ranking that takes into account “undetermined intent” raises the U.S.
rate to 2.4 per 100,000 and places its relative ranking at 25th of 27.
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Teenage Pregnancy Rate
Women experiencing teenage pregnancy are at risk for poor educational outcomes, and children born to such parents experience numerous health and
social problems (45). The U.S. rate during the 1990s of 51.1 births per 1,000
women below 20 years of age gives it a rank of 28th of 28 wealthy industrialized nations.
To summarize, the United States shows a poor population health profile on a
variety of health indicators. It does poorly on life expectancy, infant mortality
and low birthweight rates, and deaths from child injury and child maltreatment.
Teenage pregnancy rates are exceptionally high, 21 births per 1,000 higher than
for the nearest-ranked nation, the United Kingdom.
U.S. POVERTY RATES IN
INTERNATIONAL PERSPECTIVE
Poverty is increasingly seen as the greatest threat to health and human
development and a nation’s quality of life (46, 47). The experience of poverty
also results in—and contributes to—social exclusion, a process identified
by the European Union and the World Health Organization as a primary
threat to the functioning of developed societies (48, 49). Overall poverty
rates come from the 2005 edition of Society at a Glance (9). Child poverty
rates come from the League Table of Child Poverty in Rich Nations (50).
The more nuanced analyses on poverty rates over time for 11 nations—
including the United States—come from a recent Luxembourg Income Study
paper (51). Two recent volumes are devoted to comparative analyses of the
U.S. poverty profile (52, 53). I have provided elsewhere an analysis of the
political forces shaping comparative policy profiles that include the United
States (54).
National Poverty Rates and Poverty Gaps
Using internationally agreed-upon conventions of poverty as the percentage of
individuals with disposable income below 50 percent of the median income
of the entire population, the U.S. overall poverty rate for the mid-1990s was
16.6 percent. By 2000 it had increased to 17.0 percent, well above the OECD
average of 10.2 percent. The U.S. rank was 26th of 27 wealthy industrialized
nations. In terms of the gap between the average income of those living in
poverty and the median income of the entire population, the U.S. gap of 34.3
percent is above the OECD average of 27.7 percent, providing a rank of 23rd of
27 wealthy industrialized nations.
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Child Poverty—Relative and Absolute Rates
The Innocenti Research Centre’s 2000 report card provided both relative (<50%
of median income) and absolute (using the U.S. poverty standard) poverty rates
(50). During the late 1990s, the U.S. relative child poverty rate of 22.4 percent
gave a ranking of 22nd of 23 wealthy industrialized nations. This rate can be
compared with those seen for the Nordic nations (Denmark, 5.1%; Finland, 4.3%;
Norway, 3.9%; and Sweden, 2.6%), Belgium (4.4%), and Luxembourg (4.5%).
The report calculated absolute child poverty rates by applying the U.S. poverty
standard to other nations’ currencies and adjusting for purchasing power. The
U.S. poverty standard is set very low and indicates very limited resources associated with serious material and social deprivation (50). Using this standard,
the U.S. rate of 13.9 percent places it 11th of 19 nations for which these data were
available. The Nordic nations have very low absolute poverty rates (Sweden,
5.3%; Norway, 3%; Denmark, 5.1%; Finland, 6.9%), as do Belgium (7.5%) and
Luxembourg (1.2%), thereby maintaining their low-number rankings on both
kinds of poverty indicators.
Analyses from the Luxembourg Income Study
Smeeding’s study of 11 wealthy developed nations provides insights into how
the very high level of U.S. poverty comes about (51). The 11 countries represent four Anglo-Saxon nations: Canada, Ireland, the United Kingdom, and the
United States; four central European nations: Austria, Belgium, Germany, and
the Netherlands; one Southern European nation: Italy; and two Nordic nations:
Finland and Sweden.
Differences in public policy shape poverty rates. Table 1 details overall poverty
rates, rates for children, and specific rates for children in either single-parent or
two-parent households for these 11 nations. Poverty rates are also provided for
elders (seniors) and for adults with no children. These rates are based on the
international convention of a poverty cut-off of less than 50 percent of median
adjusted disposable income for individuals and families. Nations are listed from
highest overall rate to lowest.
The U.S. overall poverty rate of 17 percent places it as the highest of these 11
nations. For U.S. children living in single-parent households the poverty rate
is a striking 41.4 percent—almost four times the rate for Swedish children and
almost six times the rate for Finnish children. The U.S. elder poverty rate of
28.4 percent is the second highest, exceeded only by the strikingly high Irish
rate of 48.3 percent. The U.S. poverty rate for childless adults of 11.2 percent
exceeds every nation but Ireland (11.2%) and Canada (11.9%).
Have U.S. rates changed over time? Smeeding compares overall poverty rates
from the base year of 1987 with those of 2000. In 1987, the relative poverty rate
for the United States was 17.8 percent. For 2000 he provides two rates. The 2000
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Table 1
Relative poverty rates (percent) by type of household in 11 wealthy
industrialized nations, 1999, 2000
Households with children
(by number of parents)
Overall
All
children
1 parent
2 parents
Elders
Childless
United States
Ireland
United Kingdom
Canada
Germany
Belgium
Austria
Netherlands
Sweden
Finland
17.0
15.0
12.7
11.4
8.3
8.0
7.7
7.3
6.5
5.4
18.8
15.0
15.4
13.2
7.6
6.0
6.4
9.0
3.8
2.9
41.4
45.8
30.5
32.0
33.2
21.8
17.9
30.7
11.3
7.3
13.2
10.8
9.1
10.1
4.4
4.3
5.1
7.6
2.2
2.2
28.4
48.3
23.9
6.3
11.2
17.2
17.4
2.0
8.3
10.1
11.2
13.1
8.4
11.9
8.7
5.9
7.0
6.4
9.8
7.6
Overall average
10.3
10.1
26.6
7.6
17.0
8.9
Nation
Source: Adapted from Smeeding (51, Table 1, p. 30).
relative rate applies the same calculation to 2000 as applied in 1987: the poverty
line as less than 50 percent of the median disposable income for all residents. For
the United States, the relative poverty rate in 2000 of 17 percent showed virtually
no change from 1987. The anchored rate refers to the percentage of Americans
in 2000 living below the poverty line as calculated in 1987 and adjusted in 2000
for increases in the cost of living. The U.S. figure is 13.8 percent. There has been
some improvement in the material conditions of those at the bottom, but in relative
terms, poverty rates in the United States are unchanged from 1987 to 2000.
How does government spending influence poverty rates? Table 2 shows overall
poverty rates at various levels of government intervention. Market income refers
to income derived from gainful employment or investments and other private
sources. Relying on the market for income provides high overall poverty rates
across all nations. The U.S. poverty rate based on market income of 23.1 percent
is lower than that for most nations. Social insurance and taxes—transfers such
as child benefits and children’s allowances and changes in distribution resulting
from taxation—reduce the U.S. poverty rate to 19.3 percent. The U.S. poverty
rate associated with the provision of a few more varied benefits, termed social
assistance, is reduced to 17 percent.
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Table 2
The anti-poverty effect of government spending: percentage of
all persons living in poverty, 1999, 2000
Poverty rates
Nation
% poverty reduction
OECD social
Social
expenditures
Market insurance
Social
Social
on non-elderly,
income (and taxes) assistance assistance Overall
% of GDP
United States
Ireland
United Kingdom
Canada
Germany
Belgium
Austria
Netherlands
Sweden
Finland
23.1
29.5
31.1
21.1
28.1
34.6
31.8
21.0
28.8
17.8
19.3
21.2
23.5
12.9
10.6
8.8
9.1
9.6
11.7
11.4
17.0
16.5
12.4
11.4
8.3
8.0
7.7
7.3
6.5
5.4
16.5
28.1
24.4
38.9
62.3
74.3
71.4
54.3
59.4
36.0
26.4
44.1
60.1
46.0
70.5
76.9
75.8
65.2
77.4
69.7
2.3
5.5
7.1
5.8
7.3
9.3
7.4
9.6
11.6
10.9
Overall average
27.0
13.8
10.3
47.2
60.9
7.4
Source: Adapted from Smeeding (51, Table 4, p. 33).
Overall, U.S. social insurance programs reduce the poverty rate by 16.5 percent
and all programs reduce it by 26.4 percent. This is the smallest reduction among
these 10 nations. The overall average reduction rate is 60.9 percent for this group
of nations. Indeed, Sweden reduces its poverty rate by 77.4 percent by such
actions. Belgium, Germany, Austria, and Finland reduce their overall poverty
rates by at least 70 percent through government action.
A summary of how government intervention serves to reduce poverty is
provided by the final column in Table 2. The United States expends a frugal
2.3 percent of GDP on non-elderly citizens. In contrast, Finland and Sweden
spend more than 10 percent of GDP on these citizen benefits. The importance
of government expenditures in reducing poverty is illustrated by an analysis in
Smeeding’s paper that reveals that non-elderly cash and near-cash (housing
subsidies, active labor market subsidies, etc.) predict 61 percent (R2) of the
variation among these nations’ non-elderly poverty rates. Nations that spend
more money on these benefits have lower poverty rates. Nations that spend less
have higher poverty rates.
The percentage of low-paid workers was strongly related to the percentage
of non-elderly citizens living in poverty (51). The United States has 25 percent
Shaping Public Policy and Population Health
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of its workers earning less than 65 percent of the median wage and a poverty
rate of 17.8 percent. In contrast only 5 percent of Finnish and Swedish workers
earn low wages and the poverty rates are 4.5 percent and 6 percent, respectively. Variations in numbers of low-paid workers account for a strikingly high
85 percent (R2) of the variation among nations in the number of people in
poverty. The single best predictor of national poverty rates is the percentage of
low-wage earners. Nations that spend less of their national wealth on citizen
supports and services have higher levels of poverty—and, as other evidence
shows, poorer population health profiles (4, 55). The next sections explore the
nature of government support of citizens through transfers and programs.
U.S. PUBLIC POLICY IN PERSPECTIVE
Overall population health profiles and the extent of health inequalities within
developed nations result from variations in approaches to public policy (17, 56).
The basket of public policies—the welfare state—serves to promote human,
social, and economic development, reduce citizen insecurity, and foster health
and well-being (47).
Societal Commitments to Citizens and Government Spending
An important indicator of public commitment to supporting citizens is the percentage of GDP transferred to citizens through programs, services, cash benefits,
and investments in social infrastructure. Such infrastructure includes education,
employment training, social assistance or welfare payments, family supports,
pensions, health and social services, and other benefits.
Nations may transfer relatively small amounts, thereby allowing the marketplace to serve as the primary arbiter of how economic resources are distributed
(57). Other nations may intervene to control the marketplace by making decisions
concerning allocations of resources (58). Nations that transfer a greater proportion
of resources are more likely to show better population health profiles, and less
steep gradients in health (59).
The OECD provides indicators of government provision of supports and services (60). Among these developed nations, the average public expenditure in
2001 was 21 percent of GDP (9). There is large variation among countries, with
Denmark (29.2% of GDP) and Sweden (28.9% of GDP) the highest public
spenders. The United States ranks 26th of 30 wealthy industrialized nations
and spends just 14.8 percent of GDP on public expenditures. The only OECD
nations to allocate a smaller percentage of GDP to public expenditure are Ireland
(13.8%), Turkey (13.2%), Mexico (11.8%), and Korea (6.1%).
These differences manifest in specific policy areas. Figure 1 (parts A through D)
shows how the United States compares with other OECD nations in expenditures on health, old age, incapacity-related benefits, and families (60). The
Figure 1. This four-part figure shows (A) public and total expenditure on health, (B) public expenditure on old age, (C) public expenditure on
incapacity, and (D) public expenditure on families, all as percentage of GDP, OECD, 2001. Source: OECD, Social Expenditure Database, 2004
(www.oecd.org/els/social/expenditure).
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Figure 1. (Cont’d.)
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Figure 1. (Cont’d.)
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Figure 1. (Cont’d.)
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United States is the highest spender in total expenditure on health care. However,
it is in the mid-range on public spending for health care, as much spending is
from private sources. It is in the other benefit areas that the United States
reveals itself as a frugal spender. The United States ranks near the bottom in
allocations to old-age-related spending, primarily pensions: its spending of
14.8 percent of GDP gives it a rank of 26th of 30 among OECD nations. The
United States also ranks among the lowest spenders on incapacity- or disabilityrelated issues, allocating less than 1.1 percent of GDP, for a 25th of 29 rank. And
the United States ranks very poorly on family benefits (0.4%), achieving a rank
of 28th of 29.
Active Labor Policy
Active labor policy refers to the extent to which governments support training and
other policies that foster employment and reduce unemployment. The United
States allocates 0.53 percent of GDP to such policies. This gives it a ranking of
20th of 22 wealthy industrialized nations for which data were available (61).
PUBLIC POLICY AND CITIZEN BENEFITS:
IMPLICATIONS FOR DAY-TO-DAY LIFE
These differing commitments to supporting citizens translate into differing
conditions of day-to-day life. A set of issues are examined here: resources
available to the unemployed, level of social assistance benefits, level of minimum
wage, and level of pension benefits.
Unemployment Benefits
Figure 2 shows the percentage benefit replacement for individuals, at the average
production worker level, who are unemployed over a five-year period. For most
Americans, benefits available over the five years would be unemployment
insurance, which would expire after a year of benefits. At that point a family
with liquid assets would need to spend these before receiving social assistance
benefits. For these non-destitute families, unemployment insurance would provide only 6 percent replacement income over this period. This ranks the United
States 27th of 28 wealthy industrialized nations in its generosity of benefit. If
families qualified for social assistance, the benefit percentage would be around
30 percent, giving the United States a ranking of 26th of 28 nations.
Social Assistance or Welfare
The OECD identifies social assistance as “benefits of last resort.” On average,
U.S. social assistance benefits for a married couple with two children provide
Figure 2. Average percentage of net replacement rates over 60 months of unemployment, for four family types and two earnings levels,
without and with social assistance, 2002. Note: PRT, Portugal; CHE, Switzerland. Source: OECD (9, Figure SS1.1, p. 43).
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22 percent of median average income. This places these benefits as 28 percentage
points below the <50 percent of median income indicator of poverty. Compared
with the other nations for which these data are provided, the United States ranks
20th of 23 nations in providing these benefits of last resort (Figure 3).
Minimum Wage
Smeeding identified the percentage of low-paid workers as the best predictor
of percentage of citizens living in poverty (51). Figure 4 shows how the United
States compares with other nations in having a minimum wage that keeps people
out of poverty. For an American two-child family with one full-time minimum
wage earner, the wage received places the family at 34 percent of the median
household income, well below the poverty cut-off of 50 percent of median income.
For a family with two children and two parents working full-time at minimum
wage, the level of median income of 46 percent also places the family below the
poverty line. The U.S. ranking for families with a single parent working is 12th
of 15 wealthy industrialized nations. For families with two parents working, the
United States is ranked 14th of 15.
Pensions
The OECD provides data on the value of pension benefits provided by each
nation as a function of the gross earnings of an average production worker
(9). For a worker earning 50 percent of an average production worker, the
U.S. pension provides 61 percent of these earnings. For an American earning
the average production worker’s income, the rate is 51 percent. The rates
for average-waged U.S. workers are very low by international comparison,
giving the United States a rank of 25th of 30 wealthy industrialized
nations. For very low-paid workers, the United States achieves a lower rank
of 28th of 30.
THE U.S. PUBLIC HEALTH SCENE
Many writers have considered how the U.S. population health and public policy
profiles are linked (4, 37, 51, 52, 62). These authors include those who have been
explicitly concerned with population health and health inequalities (17–19) as
well as those focused on the U.S. political economy and the distribution of wealth
and resources (52, 53, 63). Certainly, the evidence suggests the importance of
raising these issues and seeking action on them through public policy. It is
therefore important to interrogate contemporary public health documents for
their attention to these issues.
Figure 3. Average net incomes of social assistance recipients as percentage of median equivalent household income, married couple with two
children, 2001. Note: PRT, Portugal; CHE, Switzerland. Source: OECD (9, Figure SS6.1, p. 45).
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Figure 4. Net incomes at statutory minimum wage, married couple with two children, as percentage of median household income, 2001.
Note: PRT, Portugal. Source: OECD (9, Figure SS6.2, p. 45).
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National Policy Documents and Reports
Healthy People 2010 is the United States’ national public health plan and contains
a large number of health objectives and enabling activities to achieve these (14).
Like other U.S. documents it contains a chapter on the broader determinants of
health and its health model is consistent with a broader health perspective. It has a
prominent emphasis on issues of access to health care, which is not surprising
given that 17 percent of Americans (45 million) are without health insurance
coverage.
However, closer inspection of the document reveals that the role played by
broader determinants of health is undeveloped. The Leading Health Indicators
“reflect the major health concerns in the United States at the beginning of the
21st century” (14, p. 24). These objectives—physical activity, overweight and
obesity, tobacco use, substance abuse, responsible sexual behavior, mental health,
injury and violence, environmental quality, immunization, and access to health
care—are firmly planted in the biomedical and behavioral public health model.
The Environmental Quality Leading Indicators—which could address health
determinants of income, food and housing security, early life, employment and
working conditions, and social services—are limited to “proportion of people
exposed to air that does not meet the EPA’s health-based standards for ozone”
and “proportion of non-smokers exposed to environmental tobacco smoke”
(p. 8-13). There is little recognition of the need to assess the broader determinants
of health contained in the report’s health model.
The Institute of Medicine’s The Future of the Public’s Health has similar
shortcomings (15). Its chapter on developments in population health does not
diffuse to the rest of the volume. Virtually all issues addressed are health
care–related or behaviorally focused around diet, tobacco use, or physical
activity. Policy is conceived narrowly as legislation related to risk behaviors and
health protection.
American Public Health Association policy statements and numerous “Fact
Sheets” reveal an emphasis on access to health care, the situating of health
differences in terms of racial and ethnic disparities, and attention to modifying
behavioral risk factors for disease and illness (39, 64). Leave No One Behind:
Eliminating Racial and Ethnic Disparities in Health and Life Expectancy reports
differences in health status among whites, African Americans, Hispanics and
Latinos, American Indian and Alaskan natives, and Asian Americans and Pacific
Islanders, but emphasizes unequal access to, and quality of, health care treatment.
Broadening the Scope
Some public health agencies address broader influences on health. America’s
Health Rankings provides data and rankings for states on four sets of indicators,
of which two have a broad scope (65). Community Environment (violent crime,
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lack of health insurance, infectious disease, children in poverty, and occupational
fatalities) and Health Policies (percentage of health dollars for public health,
per capita public health spending, and adequacy of prenatal care) focus on
broader health determinants. A commentary accompanying the report notes that
the infant mortality rate in the United States showed the first increase in 40
years, ranking the United States 28th internationally. Yet, like many other U.S.
analyses, the emphasis for action is primarily health care–related with a consistent
though undeveloped call to address persistent disparities, particularly among
racial/ethnic groups.
The publication by the National Association of County and City Health
Officials (NACCHO) of Tackling Health Inequities Through Public Health
Practice is a major landmark (66). It explicitly outlines the sources of health
inequalities as inequalities in social provision resulting from existing public
policy. However, as one contributor points out, a review of the websites of
every state health department found that only one—Minnesota—had an approach
consistent with this document (67).
In summary, public health activity in the United States is focused on (a) providing
access to health care and (b) ethnic and racial disparities in health with an emphasis
on health care issues. There is an apparent reluctance to consider the role played
by structural aspects of society such as the distribution of economic and social
resources in influencing health and a neglect of broad public policy.
POLITICAL, ECONOMIC, AND SOCIAL FORCES
DRIVING THESE DEVELOPMENTS
Public policy is driven by the political ideology of ruling parties. This rather
obvious conclusion, and its associated implications for improving health, has
penetrated little into the population health and health inequalities literatures
(68–70). Yet, even a cursory read of the political economy literature provides a
strong de facto argument for its validity (51, 53, 58, 71, 72).
As just one example, Esping-Andersen’s work provides a framework for understanding how nations operating under social democratic political economies
provide for strong state support for human and social development, consistent with
their ideological commitments to equity and social rights (73–75). In contrast,
the undeveloped welfare states of nations governed by liberal political economies
are guided by principles of liberty and minimal government interference with
the marketplace (57). The United States is the best example of a liberal political
economy and the public policy features associated with such states (4).
Even within liberal political economies, however, there is room for variation.
The liberal political economies include the United States, Canada, United
Kingdom, and, in some frameworks, Ireland, Australia, and New Zealand. Yet, all
of these nations—with the exception of the United States—have universal health
Shaping Public Policy and Population Health
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care systems with varying degrees of privatization. And, as noted, there are
significant differences in social provision among the United States, United
Kingdom, and Canada. And despite a clustering of liberal welfare states on
numerous indicators, there is variation among them. How then can we explain the
United States being an outlier even within the liberal political economy camp?
Analyses of the political economy of the United States and the influences
that have shaped it are available (53, 63, 76–79). Suffice it to state that the U.S.
welfare state developed later and is far less extensive than those in most other
wealthy developed nations. However, as noted by Siddiqi and Hertzman (80),
the striking differences between the United States and other liberal nations in
health and social spending are of more recent origin.
Hofrichter’s volume on health and social justice considers these issues (19).
Since the Reagan era there has been a profound shift in power and influence away
from governments and organized labor and toward the corporate sector (37).
This had led to an unprecedented concentration of wealth among the wealthiest
of Americans (81). Associated with this power shift have been unprecedented
reductions in taxes for the wealthy and a hardening of attitudes toward the
least well-off and the poor (63). Neoliberalism—the belief that the marketplace
should be the primary arbiter of how resources are allocated—becomes the
justifying discourse for such power shifts (37, 82). Hofrichter provides a succinct
summary of these developments (5, pp. 23–24):
Since 1973, the power of the working class and labor has been weakening in
the United States. The deterritorialization of production, the decline of labor
unions, and reduced voter turnout have contributed to this weakening, as
well as the absence of any truly oppositional political party. In the United
States, the federal government has increasingly come under greater control
of well-financed corporations and wealthy individuals that make enormous
monetary contributions to political campaigns. These changes have given
capitalist forces, investors, and owners of significant property an almost
overwhelming edge in political power to act against the social well-being
of the population. . . .
Specific policies supported by capital to strengthen their position in
relation to the workforce include failure to increase the minimum wage,
reductions in unemployment compensation, elimination of health and safety
regulations, weakening rights of labor to organize, and opposition to full
employment and long-term job opportunities. All of these forces result in
potential stresses and exposures leading to poorer health and well-being.
Yet, American history has recorded frequent reversals of such concentrations
of power and influence (63, 83). The most recent examples are the social changes
associated with the 1960s, the New Deal, and the Progressive Era (53, 84). In
addition there are numerous advocacy groups whose purpose is to address these
problems in U.S. public policy (85, 86).
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THE ROLE OF PUBLIC HEALTH IN LINKING POPULATION
HEALTH WITH PUBLIC POLICY
There is no shortage of suggestions on how public health researchers and workers
could begin to address the structural issues that shape the presence of health
inequalities and the U.S. population health profile (19, 66, 84, 87, 88). It is not
my intention to repeat these here. But for the most part these suggestions have
not been taken up by the U.S. public health community. Why might this be so?
In a series of 12 interviews with prominent health researchers and policy
advocates across the United States, I investigated the reasons for public health
neglect of these broader issues. No surprises emerged from these analyses. The
rise of neoliberal and neoconservative forces—reflecting both a breakdown of the
postwar consensus among government, business, and labor and the legacies of
the Reagan Revolution—served to actively suppress virtually all public health
activity related to addressing broader determinants of health. This is especially the
case for issues related to income. In addition, social class as an object of inquiry
and analysis has frequently been the subject of derision by academic health
researchers, policymakers, and elected officials (8).
Clearly, there are formidable barriers to developing health-supporting public
policy in the United States. I do not argue that the public health community can
by itself reverse these trends. Nor, however, do I believe that the public health
community should endorse these fundamental shifts in power by ignoring them.
I propose that public health researchers and workers raise and investigate—in
an objective manner—the same issues being raised by public health researchers
and workers in many other wealthy developed nations: the role of social determinants of health and their public policy antecedents in shaping population
health and creating health inequalities.
Public health workers and researchers could play three key roles in raising
the profile of these issues: education, motivation, and activation in support of the
social determinants of health. Public health researchers and workers, who know
the health situation and its causes best, are ideally suited for such a role. Through
such action, political supports for public policy on the social determinants of
health could be strengthened.
Educate
In the United States, the public remains woefully uninformed about the social
determinants of health and their public policy antecedents (5). The population has
been subject to continuous messaging on the benefits of a business-oriented
laissez-faire approach to governance (82). What this messaging has not included
is the societal effects of this approach: increasing income and wealth inequality,
persistent poverty, and a poor population health profile (76). These effects are
Shaping Public Policy and Population Health
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profound and objectively influence—for the worse—the health and well-being
of a majority of Americans (5).
Thousands of Americans are in occupations concerned with public health
research and action. These researchers and workers could take advantage of
the citizenry’s concern with health, and the evidence of the importance of the
social determinants of health—and their public policy antecedents—to offer
an alternative to the dominant biomedical and lifestyle discourse. At a minimum, the public health community could carry out, and publicize the findings from, critical analyses of the social determinants of health. This is not a
question of being subversive—it is a simple matter of information and knowledge transfer.
There is no shortage of potential analyses. Social determinants of health such
as poverty, housing and food insecurity, and social exclusion are the primary
antecedents of just about every affliction known to humankind (89). My short
list includes coronary heart disease, type II diabetes, arthritis, stroke, many forms
of cancer, respiratory disease, HIV/AIDS, Alzheimer’s, asthma, injuries, death
from injuries, mental illness, suicide, emergency room visits, school drop-out,
delinquency and crime, unemployment, alienation, and depression. Recall that
U.S. public health documents describe these health determinants—but then fail
to follow through on their implications (14, 15).
Hofrichter’s recent volume brings together much of the U.S. literature on its
problematic population health profile and the extent and causes of its health
inequalities (19). The recent NACCHO document on addressing health inequities
is also an important resource (66). The upcoming 2007 release of a major
documentary series tentatively titled Unnatural Causes: Is Inequality Making
Us Sick?—which is being coordinated with a public engagement campaign—
has the potential to support these efforts. The four-hour series, produced
by California Newsreel for PBS (Public Broadcasting Service) broadcast and
DVD release, focuses on the underlying causes of socioeconomic and
racial disparities in health. The associated campaign aims to reframe the U.S.
debate on health by moving the discussion to consider the social determinants
of health (90).
Motivate
The public health community can help shift public, professional, and policymakers’ focus away from the dominant biomedical and lifestyle health paradigms
by collecting and presenting stories on the impact of social determinants of health
on people’s lives. Ethnographic and qualitative approaches to individual and
community health produce vivid illustrations of the importance of these issues
(91, 92). There is some indication that policymakers, and certainly the media, are
responsive to such forms of evidence (93). In the United States such approaches
clearly constitute a small proportion of health promotion and health services
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research (94). There is an increasing focus on community-based research, but
these activities are frequently narrow and seem unwilling to allow citizens to raise
issues concerned with income distribution, employment and labor issues, and
citizen participation in government priorities and actions (95, 96). Such activities
can be a rich source of insights about the mainsprings of health and means of
influencing public policy by allowing community members to provide their own
critical reflections on society, power, and inequality (7). Ultimately, the end of
such activities should be the creation of social movements in support of health.
The People’s Health Assembly is but one example of such a movement in
support of health.
Activate
The final role is the most important but potentially the most difficult: backing
political action in support of health. The quality of numerous social determinants
of health within a jurisdiction is shaped by the political ideology of governing
parties. Nations where the quality of the social determinants of health is high
have had a greater extent of rule by social democratic parties of the left (52,
53, 58). Specifically, nations with a larger share of left-party cabinet members
from 1946 to the 1990s had the lowest child poverty rates and highest social
expenditures; nations with less left-share had the highest poverty rates and
lowest social expenditures (52). It has also been documented that poverty rates
are lower and government support in favor of health—the extent of government
transfers—is higher when popular vote is more directly translated into political
representation through proportional representation (53).
The United States has not had a member of a left political party in the federal
cabinet, nor does it have a viable left party. The United States also does not
have proportional representation—the lack of which is associated with higher
poverty rates, less government action in support of health, and poorer population
health profiles (53). Proportional representation provides for an ongoing influence
of left parties regardless of which party forms the government. The strength of the
labor movement is also a strong determinant of both public policy and population
health (55). The United States has the lowest union membership density (13%) and
lowest collective agreement coverage (14%) of any wealthy industrialized nation
(97). Strengthening workers’ rights to organize and improve wages, benefits, and
employment security is clearly a public health issue that requires action in the
political sphere. These are very difficult issues.
Municipal governments may be more responsive to citizen grassroots action
in support of public policy that enhances health (66, 67). Considering the preponderance of evidence on the importance of public policy in support of health, the
problematic U.S. population health profile, and the raising of these issues by
various citizen groups, the public health community has the potential to join
and inform these issues.
Shaping Public Policy and Population Health
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CONCLUSION
Promoting population health and addressing health inequalities requires recognition of the public policy conditions necessary for health. These conditions
include equitable distribution of income and wealth, and responsive programs
that support citizens. While the United States is a public policy outlier among
wealthy industrialized nations, it has had periods of progressive activity in support
of its citizens (63). There is also increasing recognition that the U.S. model of
public policy is inappropriate for meeting the challenges of a post-industrial
economy (98).
Political reversals are possible in democracies. The United Kingdom emerged
from two decades of neoliberal conservative rule to elect a Labour government
in 1997 that was committed to reducing health inequalities. New Zealand took
a similar neoliberal course during the 1990s, but has since at least halted this
direction with the possibility of future policy reversals.
This analysis of the social determinants of health and their public policy
antecedents suggests that the best means of promoting population health and
reducing health inequalities requires citizens being informed about the political
and economic forces that shape the health of a society. Once so empowered, they
can consider political and other means of influencing these forces. It is not
unreasonable that a shift to the left would be the preferred direction. Providing
support for such a role is not one that public health researchers and workers
have usually considered appropriate. This appears to be a rather daunting task,
but one that holds the best hope of promoting the health of Americans.
Note — Content in this article was presented at the Health Disparities: From
Genetics to Health Policy Symposium at the Rammelkamp Center for Education
and Research, Cleveland, Ohio, September 27, 2006.
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Direct reprint requests to:
Dennis Raphael
School of Health Policy and Management
York University
4700 Keele Street
Toronto, ON M3J 1P3
Canada
e-mail: [email protected]