Academic journal article Health Sociology Review

Health Inequity and Its Social Determinants: A Sociological Commentary

Academic journal article Health Sociology Review

Health Inequity and Its Social Determinants: A Sociological Commentary

Article excerpt


In December 2006 The Lancet published a prestigious lecture presented at the Royal College of Physicians by the acclaimed Australian doctor and epidemiologist, Professor Sir Michael Marmot, on the subject of 'health in an unequal world'. Marmot's lecture outlined the breadth and depth of health inequalities within and between countries across the globe. Impressive for its detail and incisiveness, the information it provided on international health patterns was nonetheless very familiar to those acquainted with the social dimensions of health, particularly those involved in teaching or researching health from a sociological perspective. So, too, was the lecture's central 'take-home' message: 'Inequalities in health are not inevitable...(They are closely linked to) the way we organise our affairs in society' (Marmot, 2006: 9). Much of the lecture was taken up with explanation of how this is the case and what researchers and physicians can do if they wish to be part of the solution rather than part of the problem.

So what kind of approach did Marmot advance in his explanation? Not an explicitly sociological one. Rather, the patterns of health inequalities were explained in terms of what Marmot called a 'social determinants of health' framework: a social scientific approach that has been a major player in shaping prevailing international research and policy-based understandings of social inequalities and health, and of public strategies to advance health equity (Marmot and Wilkinson 2006). In this article I outline and discuss this model of understanding, and intervening in, health inequities from a sociological perspective. Its consequences, I argue, may be significantly less efficacious than intended in the absence of a critical sociological examination of how 'the social' produces and determines health.

Health disparities and equity: A new research and policy discourse

Arguably the current definitive text on the social determinants of health is the book of that name edited by Michael Marmot and Richard Wilkinson (2006). It was first published by the World Health Organisation (WHO) under the title, Social Determinants of Health: The Solid Facts (Wilkinson and Marmot 1998). It built on work that began to emerge in the field of health disparities and equity in the 1980s (see, for example, Townsend and Davidson 1982; Daniels 1985; Mooney 1987) and that gained considerable momentum in the 1990s. One of the contributors to this early work, the health economist, Gavin Mooney (1987), posed the question, What does equity in health mean?' He replied that there was no one, correct' answer because the various definitions that were appropriate for adoption in developing a response involved differing values and purposes. As his response suggested, equity is an inherently normative concept. Nevertheless, by 1990 the European Regional Office for the World Health Organisation had formulated a decisive response to the question. It outlined basic concepts and principles, subsequently elaborated in a publication by the author of the WHO report (Whitehead 1992). These were taken up in a variety of international studies and enquiries into health disparities throughout the 1990s (see, for example, Culyer and Wagstaff 1993; deKadt and Tasca 1993; Birdsall and Hecht 1995; Braveman 1996; Mackenback and Kunst 1997; Wilkinson 1997; Acheson et al 1998).

The WHO (1990) paper proposed that while health inequities are indivisibly related to health inequalities or differences, they are not the same. Health inequities should be understood in terms of 'differences in health that are unnecessary, avoidable, unfair and unjust' in relation to both individuals and populations. The achievement of health equity involved both individuals and populations in a project towards the elimination of avoidable health inequalities. Its fundamental objective was to promote the opportunity for individuals to achieve their maximum health potential and to face no disadvantages in doing so if the barriers to the attainment of such a goal could be avoided (Whitehead 1992). …

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