A Discourse Analysis of the Social Determinants of Health Dennis Raphael*

Critical Public Health Vol. 21, No. 2, June 2011, 221–236 A discourse analysis of the social determinants of health Dennis Raphael* School of Health Policy and Management, York University, Toronto, ON M3J 1P3, Canada (Received 15 September 2009; final version received 5 April 2010) The social determinants of health (SDH) concept is common to Canadian policy documents and reports. Yet, little effort is undertaken to strengthen their quality and promote their more equitable distribution through public policy action. Much of this has to do with the SDH concept conflicting with current governmental approaches of welfare state retrenchment and deference to the dominant societal institution in Canada, the marketplace. In addition, many SDH researchers and implementers of SDH-related concepts are reluctant to identify the public policy implications of the SDH concept. The result is a variety of SDH discourses that differ greatly in their explication of the SDH concept and their implications for action. This article identifies these various SDH discourses with the goal of noting their contributions and limitations in the service of advancing the SDH agenda in Canada and elsewhere. Keywords: public policy; socio-economic; health inequalities Introduction Social determinants of health (SDH) refer to the societal factors – and the unequal distribution of these factors – that contribute to both the overall health of Canadians and existing inequalities in health (Graham 2004a). With the publication of the Commission on the Social Determinants of Health’s final report and those of its knowledge hubs, the SDH concept has achieved a prominence that makes it difficult for policymakers, health researchers and professionals to ignore (Commission on the Social Determinants of Health 2008). This has certainly been the case in Canada where the SDH figure prominently in health policy documents produced by the Federal government (Public Health Agency of Canada 2007, 2008a), the Chief Health Officer of Canada (Butler-Jones 2008), the Canadian Senate (Senate Subcommittee on Population Health 2008), numerous public health and social development organizations and agencies (United Nations Association of Canada 2006, Canadian Public Health Association 2008, Chronic Disease Alliance of Downloaded by [C M Hincks Treatment Centre], [Dennis Raphael] at 12:24 01 August 2011 Ontario 2008) and research funding agencies (Institute of Population and Public Health 2003, Canadian Institutes of Health Research 2005). Even the business- oriented Conference Board of Canada has established an initiative focused on the social and economic determinants of health (Conference Board of Canada 2008). *Email: [email protected] ISSN 0958–1596 print/ISSN 1469–3682 online ß 2011 Taylor & Francis DOI: 10.1080/09581596.2010.485606 http://www.informaworld.com 222 D. Raphael The content of these documents is consistent with the view that (1) SDH are important influences upon the health of individuals, communities and jurisdictions as a whole and (2) SDH represent the quantity and quality of a variety of resources a society makes available to its members. All imply that something should be done to strengthen them. It is well documented, however, that actual implementation of these concepts in Canada lags well behind other jurisdictions (Canadian Population Health Initiative 2002, Lavis 2002, Collins et al. 2007, Raphael et al. 2008). The SDH concept – and its public policy implications – conflict with current governmental approaches that reflect welfare state retrenchment and deference to the dominant societal institution in Canada, the marketplace (Raphael and Bryant 2006, Irwin and Scali 2007). The result is that while Canada has a reputation as a ‘health promotion and population health powerhouse’ (Restrepo 1996, Raphael 2008a), the actual reality is that inequalities in income and wealth have increased at the same time that governments have weakened their commitments to provide citizens with various benefits and supports (Organisation for Economic Co-operation and Development 2008, Raphael 2008b, Bryant 2009). The result of this has been that increasing numbers of Canadians are coming to experience adverse SDH (e.g. low incomes, food, housing, and employment insecurity, etc.; Bryant et al. 2009). Since these adverse experiences do not occur for all Canadians, the argument can also be made that the distribution of the SDH among Canadians is becoming increasingly unequal (Graham 2004a). There is also evidence that improvements in key health outcomes such as life expectancy and premature years of life lost are not keeping pace with improvements seen among many Organisation for Economic Co-operation and Development nations (OECD 2007). In the case of infant mortality, Canada’s rate may actually be increasing (Wilkins 2007). An additional problem is that many SDH researchers and those attempting to implement SDH-related concepts are reluctant to identify the public policy implications of the SDH concept (Poland et al. 1998, Robertson 1998, Coburn 2006). This tendency is especially striking among disease-related research publica- tions and policy documents where extensive discussion is provided in early sections of the importance of the SDH for various afflictions (e.g. cardiovascular disease, type II diabetes, cancers, respiratory disease, etc.), but recommendations are limited to the promotion of so-called ‘healthy lifestyle choices’, such as the eating of fruits and vegetables, increased physical activity, and the avoidance of tobacco and excessive alcohol use (Basinski 1999, Heart and Stroke Foundation of Canada 1999, Hux et al. 2002, Health Canada 2003, Canadian Diabetes Association 2008, Public Health Agency of Canada 2008b). Even the recent report by the Chief Health Officer of Canada on inequalities in Downloaded by [C M Hincks Treatment Centre], [Dennis Raphael] at 12:24 01 August 2011 health and the importance of the SDH demonstrates this reluctance. An analysis of the report argues that it fails to recognize the role that governments can play in ‘addressing the underlying structural drivers of health inequalities and the treatment of basic needs’ (Kirkpatrick and McIntyre 2009, p. 94). There appears to be an even greater reluctance to consider the political and ideological sources of the inequitable distribution of SDH among Canadians. This shortcoming is especially apparent among ‘population health researchers’ working within the Canadian Institute for Advanced Research framework (Poland et al. 1998, Raphael and Bryant 2002, Coburn et al. 2003).1 The result is the presence of a variety Critical Public Health 223 of SDH discourses that differ greatly in their explication of the SDH concept and their implications for action. In this article, I identify these various discourses, and by noting their contributions and limitations, aim to advance the SDH agenda in Canada and elsewhere. SDH discourses As noted earlier, SDH refer to the societal factors – and the unequal distribution of these factors – that contribute to both the overall health of Canadians and existing inequalities in health (Graham 2004a). Since the modern introduction of the term SDH (Tarlov 1996), a variety of conceptualizations – all clearly referring to the impact of societal factors upon health – have appeared (Table 1). The evidence base in support of the importance of the SDH is now extensive (Davey Smith 2003, Wilkinson and Marmot 2003, Commission on the Social Determinants of Health 2008). Among those researching and engaged in SDH- related activities, a consensus exists that non-medical and non-behavioural risk factors are worthy of attention, but I have observed profound differences in how this consensus plays out in research and professional activity. To my mind, this variation is not merely about paradigms that define intellectual world views about how such phenomena can be understood or investigated (Kuhn 1970, Guba 1990). This variation rather represents Foucaultian discourses which – since they involve issues of legitimation, power, and coercion – exert a much more powerful influence upon research and practice: Foucault refers to discourses as systems of thoughts composed of ideas, attitudes, courses of actions, beliefs, and practices that systematically construct the subjects and the worlds of which they speak. He traces the role of discourses in wider social processes of legitimating and power, emphasizing the constitution of current truths, how they are maintained and what power relations they carry with them (Lessa 2006, p. 285). The reason why I raise the Foucaultian concept of discourse is that these SDH discourses appear to direct the kinds of research and professional activities that are deemed acceptable, i.e. fundable in the case of research2 and institutional budgeting,3 and career-enhancing in terms of personal futures.4 The result is that there are just a handful of Canadian health researchers and workers who write and talk publicly about the economic and political forces that shape the quality of the SDH.5 In the following sections, I examine the contribution – and deficiencies – of the various SDH discourses and how they may play out in SDH research activity and professional practice (Table 2). Downloaded by [C M Hincks Treatment Centre], [Dennis Raphael] at 12:24 01 August 2011 Discourse 1: SDH as identifying those in need of health and social services In this discourse, individuals and communities who experience an inter-connected set of adverse SDH (e.g., growing up in a

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