Are the bigger fish upstream?

Hannah Badland PhD is Principal Research Fellow, Centre for Urban Research, RMIT University. She is supported by an RMIT University Vice Chancellor’s Senior Research Fellowship and is the Australian Health Promotion Association Thinker in Residence.

Hannah Badland considers the potentials and pitfalls of focusing on social determinants of health

Social determinants of health are the conditions in which people are born, grow, live, work and age. These are shaped by the distribution of resources, power and money and are broadly understood as the ‘upstream’ contributors to health and wellbeing – or, put more simply, the causes of the causes.

With recent estimates suggesting that 23 per cent of the global burden of disease is attributable to the environment, factors like community and social infrastructure, education, employment, housing and transport are important levers for health and wellbeing.

And yet we still tend to focus on the symptoms of social problems rather than the core issues. For example, obesity/overweight has historically been viewed as caused by dietary patterns and consumption (downstream), rather than access to and availability of healthy and unhealthy food (upstream).

How we frame our responses to such challenges is important, as it guides the focus of policies, interventions and resources to be more downstream (individual) or upstream (population).

Health inequities persist, and in some countries are increasing. Time after time it has been shown that the poorer you are, the poorer your health. This social gradient is unfair and unjust, and it impacts everyone: as health declines for those of the lowest socio-economic status, health outcomes for those of higher socioeconomic status are also compromised.

Conversely, improving the resources and infrastructure in local communities might benefi everyone, but particularly those who are most dependent on accessing services close to where they live (such as children, older people and the socially excluded).

The broad nature of the social determinants of health means that many different sectors have a stake, including policy-makers who are grappling with major urban challenges such as providing affordable housing and loca employment opportunities.

This can be a good thing, presenting opportunities for mutually beneficial outcomes. But collaboration needs to be built in early, into the agenda-setting stage of projects.

As an example, the New Urban Agenda is a global framework endorsed by the United Nations in 2016. Through 17 Sustainable Development Goals, it advocates collaboration between the government, non-government and private sectors to work towards sustainable and equitable urban development over the next two decades. This includes the delivery of local infrastructure, services and housing to improve social determinants of health.

Reducing health discrepancies through reducing inequalities is possible: the income-wealth gap between the rich and the poor has been narrowing in some countries, and some countries have smaller gaps than others.

However, opportunities to improve the social determinants of health are place-specific, with different communities having different needs. It’s even possible that poorly planned or implemented interventions might actually widen inequalities – for example, through unintended gentrification of neighbourhoods, leading to increased housing costs and local people being pushed out.

There are some important messages for policy-makers and urban planners tasked with identifying ways to improve people’s health and reduce health inequities.

Our neighbourhoods should be designed to become more ‘liveable’ by offering more affordable housing, opportunities to socialise, a range of transport, and access to local education and employment.

One of the principle commitments of the New Urban Agenda is ‘leaving no one behind’. Interventions into the social determinants of health need to be implemented in ways that meet the needs of everyone living in the area, including the most vulnerable.

We need to continue to monitor  the impact of interventions, and get a better understanding of how these issues relate to the wider urban and social systems impacting our health.