In this short piece, I argue for and introduce a new geographical analogy for the so-called social determinants of health framework.
Introduction
The social determinants of health (SDOH) remain the dominant conceptual framework for researching health inequities and other indicators, for designing related policy and interventions in communities, settings and populations, and for measuring and evaluating their impact. There is near-universal consensus that diverse health outcomes arise via social and structural factors, and that health is neither a function solely of either health/medical care or individual biology, genetic variation, choices or behaviour.
The riverine stream analogy
Most visual and narrative discourses of the SDOH framework deploy a riverine or stream metaphor. They define a set of upstream forces or determinants influencing downstream health, disease, or illness outcomes, and the inequalities or disparities in those outcomes. In this, there is a sort of “billiard ball” (or "pool table") picture or ontology of linear disease and illness causation. Here, an absence, scarcity, quality, excess, intensity, or mere presence of a one-off or more typically enduring upstream determinant or risk factor is assumed to produce negative and unequal impacts in an individual person’s, group’s, community’s, or population’s health downstream. Using this mechanistic, positivist and structure-separate-from-agency view of reality, the SDOH framework seeks to help us identify and analyse the determinants responsible – the impacting billiard ball or balls – for different types of disease, illness and inequalities (whose presence, severity, pattern of distribution, and persistence is objectively measured by outcomes).
Later a midstream determinant crept into the SDOH framework. This positions individual persons and their agency – their health needs, resources, behaviour, and choices - between upstream determinants and downstream outcomes (and sometimes downstream determinants too .. the picture is confused). This three-part framework is now being adopted. For example, the Future of Nursing 2020-30 report contains several recommendations for the 3.3m professional nurses in the US (and globally) to better understand, engage with and address the SDOH using it.
The shortcomings of SDOH
Despite evidence of the mediating effects of certain social determinants (notably education, income and wealth - easier to measure) on health status, the SDOH framework suffers from several shortcomings. These include ambiguity of purpose, confused terminology, wide heterogeneity within determinants and categories, uncertainty about what goes in the up-, mid- or down-stream (as above), lack of specificity of causal mechanisms, and several methodological and even ethical difficulties (I have a new paper that describes all these coming soon).
At any spatial and practical level of analysis and operation, it is hard to know where to start, where to focus and what exactly to change. A number of tendencies and consequences arise from these challenges. Here are seven in summary form:
An inability to understand and address complex, multi-determinant embodied states of disease (or conditions or some other label) such as pain or obesity where there is wide difference in their origin and experience
Difficulty linking mental health or illness to specific determinants or risk factors
A tendency to provide for people’s individual resource needs on a short-term need basis rather than addressing contexts of their disease/illness origin, formation and recurrence
Short-term efforts focused on more observable problems and easier to design prescriptions, driven by the strictures of grant funding
Ongoing creation of remnant disease symptom spaces for valorisation by industry, especially pharmaceutical companies
A backstop of health education and literacy programs that rely on the simplistic assumption that to be healthy requires a person to merely know and act on provided scientific or truthful facts
Unintended consequences of the above such as further inequalities and opioid addiction (itself now a legitimate SDOH social context of focus)
There is no SDOH pot of gold
In the absence of robust causal accounts of the mediation of specific health inequities and outcomes in particular contexts, settings and populations, finding and addressing social determinants is like chasing a rainbow. They shift around depending on our perspective, position, purpose and method. They can be present and yet not present in the same place at the same time. Whilst the SDOH framework justifiably widens the purview of possible and necessary action on health and health inequities, it does little to guide useful action at scale and with enduring impact. It seems there is no pot of gold at the end of the SDOH rainbow.
A key reason for this I argue is that the linear SDOH billiard ball picture is overly simplistic. It does not reflect the complex multi-dimensional entangled realities of disease-illness causation nor capture their processes of differentiation. Fundamentally, by reducing disease-illness origins to discrete determinants, risk factors and their outcomes, the SDOH framework neglects the intrinsic complexity of people’s lives. It fails to see and understand how important differences in real experience play out across and within so-called categories of determinants and social context. Consequently, it is unable to produce the deep insights needed to guide actions that reduce health inequalities on a sustained basis in specific places. The framework only “goes around” its object of health; it does not enter deeply enough into diverse real experiences with health, their origins, formation, differentiation, and persistence. With social context, heterogeneity, and uncertainty everywhere, SDOH only directs us to pull at different strands of determinants of (unequal) health problems in an experimental fashion based on what is or can be measured, correlated and is notionally ethical[1].
If the river / stream metaphor does not reflect reality, we can start to address the above challenges by coming up with an alternative one that does. Sticking with the geomorphological theme (I am a geographer after all), here is my suggestion.
The first time you will ever read about mangrove forests in relation to health and inequities
A mangrove is a wetland forest that sits at the interface of the land, the ocean, and the atmosphere in tropical climates. They are centres for the flow and transfer of energy and matter between these connected systems. Here is a picture of one (in the Tha Pom canal area, Krabi province, Thailand) showing their complex root structure and I think if you look closely, two people sunbathing in the shade.
With dense, below water-level connected rhizomatic root systems, mangrove forests are typically subjected to repeated twice-daily incursions of tidal water, with some parts becoming more-or-less flooded and others more sedimented or silted-up. Unfortunately, they are disappearing. About 2% of global mangrove area is being lost each year, mostly due to illegal shrimp farming practices and the cutting down of trees for charcoal for fires. Here is an excellent report on their threats and loss together with more pics.
Using the mangrove forest as an analogy for disease and illness creation, we see that experiences with health, chronic disease and mental illness all arise via the interaction of many overlapping, not easily differentiated multi-directional systems- environmental, social, cultural, material, semiotic, economic, political, healthcare and so on - each bearing certain entities, ideas, forces, events, relations and affects forming experience. Just like the tidal repetitions and repeated exploitative human farming and cutting practices, we see that buried in these forces are tendencies of our own practices – tendencies of observation, representation, categorisation, measurement (data is a representation), valuation, organisation, and action.
In a mangrovian analogy, health is no longer seen as distinct or downstream from social or structural external and upstream determinants. Rather, health is entangled in a complex milieu of interacting forces, flows and processes. Here, disease and illness (whether mental or physical it does not matter) is akin to the drying-up parts of a decaying mangrove forest. It is a sedimentation, a slowing up, a loss of energy, and a diminished capacity to be, do and become. It is a reduced flow or duration and creation in actual experience.
My argument then is this. To address disease, illness and health inequities, we need an alternative framework for learning, design and creation. We need a new system of thought that supports deeper understanding of the formative conditions of our real experiences (more widely as well as with health), one that surfaces novel paths and possibilities for creating, valuing, and sustaining the real experiences with health (and beyond) that people desire.