In a new book, Harsh Mander illustrates how poor social conditions can cause long-term illnesses

In the language of policy, what do we learn from the small band of enlightened colonial administrators during the deadly Bombay plague epidemic and the singular life journey of Norman Bethune? That a person’s health requires not just quality health care services but also attention to what we call the “social determinants of health”, which include nutrition, decent work, decent housing, clean water, ventilation, sanitation, social protection and so much else. Through rigorous empirical studies, many scholars helped further our understanding of the social determinants of health and consequent state responsibilities.

One of the first significant studies that identified social and economic factors that cause and fuel the spread of certain diseases was notably by Friedrich Engels, German philosopher and close collaborator of Karl Marx. Typhus, or scarlet fever, was widespread at that time among the London working classes, and Engels saw the link between the highly unsanitary conditions in which they were forced to live and their susceptibility to this deadly ailment.

Thomas McKeown a century later followed up on Engel’s work and found that as sanitation and hygiene improved in the second half of the 19th century, mortality rates by communicable diseases fell – although he hypothesised that increase in food production and improvement in food supply were the primary contributory factors.

Other important empirical studies include one by Drummond and Mason, in which they established how acute financial restrictions often prevent the creation of a diabetic regime by impoverished patients.

Another public health scholar, Sheila Zurbrigg, concluded from her study of Punjab in the 19th and 20th centuries that poor nutritional standards of impoverished residents led to higher levels of mortality from malaria.

She noted that Punjab, from the late 19th century, was struck by huge malaria epidemics with high mortality. She attributed this to rising food grain prices in the near-famine-like conditions that prevailed then. She traced how the development of the railways from 1870 made it possible for large landowners to transport surplus food grain to markets rather than to store it in the village. This led to a sharp rise in food grain prices that particularly hit landless workers and small farmers. A shift in payment of wages in cash rather than kind and huge burdens of debt to moneylenders contributed further to near-starvation conditions in Punjab, which she links to high malaria deaths.

Also badly stricken by malaria were Kashmiri shawl weavers, who had arrived in Punjab as famine immigrants in the 1830s. The textile industry collapsed because of the influx of cheaper British textiles. This greatly impoverished the Kashmiri weavers, who also died in large numbers during the malaria epidemics. Zurbrigg concludes that while the provinces of Punjab were plagued by malaria from 1868 to the 1940s, the poorest segments of society, suffering from malnutrition, accounted for the larger share of malaria mortality rates.

Scholars have also found that the burden of chronic illnesses is especially significant in low- and middle-income nations. Rising rates of non-communicable diseases are compounded by persistent infectious epidemics. Countries such as Brazil, China, India and Pakistan report higher mortality rates from chronic diseases than from infectious diseases, maternal health issues and nutritional deficiencies combined. Many of the risk factors for these conditions – such as poor diet, smoking and alcohol abuse – are often attributed to individual lifestyle choices. However, these behaviours are strongly influenced by social disadvantage and economic deprivation. Effective health policy must, therefore, go beyond individual behavioural interventions and address the broader social and economic conditions that make disadvantaged populations more vulnerable to disease.

The centrality of the nature of, access to, and terms of work in impacting health and health disparities in high-income countries is the subject of another important study. The study underlines how gender, race, age and migrant status intersect with work to perpetuate health disparities. For example, women, people of colour and migrant workers are often concentrated in precarious, low-wage jobs with higher health risks. Even more vulnerable are temporary contract workers and refugees, who often perform physically demanding and hazardous jobs. Gig and contract work depend on precarious employment, lacking job security, adequate income and social protections, leading to heightened health risks. Many workers work excessive hours with irregular schedules, which contributes further to their significant health problems, such as cardiovascular diseases, mental health issues and work-related injuries.

A major qualitative study from Uganda sheds significant light on the experiences of access to public health care by people with disabilities and older people. Although located in Uganda, its findings have a much greater universality for these particularly vulnerable groups. Research found that people with disabilities and older people encountered significant challenges in receiving quality medical care. Medical facilities were inadequate, trained health care personnel lacking and essential drugs were scarce. In a myriad ways, persons with disabilities felt devalued by their communities and health care providers, often being treated as incapable or burdensome: “worthless” or “a waste of time”. Another major issue was the financial burden of health care. Many older people and individuals with disabilities lived in poverty and struggled to afford medical treatments. Even when medications were prescribed, purchasing them was often impossible due to high costs.

Many facilities were physically inaccessible to individuals with mobility impairments, while deaf individuals faced communication barriers due to the absence of sign language interpreters. Women with disabilities encountered severe reproductive health challenges, including a lack of specialised services for pregnant women with disabilities. Some reported that medical staff could not effectively communicate with them, leading to life-threatening situations during childbirth.

A notable and influential conclusion by Michael Marmot was that there is little point treating people and sending them back to conditions that were the cause of sickness. If further illness is to be prevented, the health inequalities to which they are subjected must be reversed. He argued that addressing health inequalities requires attention to the social determinants of health. Perceiving the patient in a broader context also should become a part of the practice of medicine. Paediatricians, he notes, recognise the importance of working on wider issues such as early child development, beyond treating a child. Child poverty has a major impact on the life chances of the child in terms of standard of living and opportunities. It is important therefore to understand the circumstances under which children are being raised to address their health challenges.

The powerful insights that colonial administrators battling the late-19th century Bombay plague, and Norman Bethune in his war against tuberculosis learned and several public health researchers garnered was that a person’s health is influenced powerfully by factors apart from health services, clinics, hospitals, doctors, nurses, drugs and diagnostics. This lesson was much longer in coming among international bodies. However, today this is widely acknowledged.

The WHO, for instance, defines the social determinants of health as the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. It also recognises the much higher vulnerability to disease of impoverished people. It observes that “in countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health”.

Importantly, it notes that research establishes empirically that the social determinants are often more important than health care services or lifestyle choices in influencing health. Studies estimate that these social determinants account for between 30–55% of health outcomes. Also that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector.

It identifies many examples of the social determinants of health. These can impact health in positive and negative ways. These include income, social protection, education, unemployment and job insecurity, conditions in the workplace, food security, housing, basic amenities and the environment, social exclusion and discrimination, and conflict.

The Human Rights Research Centre observes that “Worldwide, disadvantaged populations continuously experience worsening health”. In 2016, non-communicable diseases were the most likely cause of the 15 million premature deaths that occurred in low- and middle-income countries. In addition, the under-five mortality rate is more than eight times higher in African regions than in European regions.

The Committee on Economic, Social and Cultural Rights, in its 22nd session on August 11, 2000, issued its General Comment No 14 that elaborated the social determinants of health. It underlined that the right to health is closely related to and dependent upon the realisation of other human needs and rights. These include food and nutrition, housing, safe and potable water, adequate sanitation, safe and healthy working conditions, healthy occupational and environmental conditions, access to health-related education and information, including on sexual and reproductive health, human dignity, freedom from discrimination, equality, the prohibition against torture, privacy, access to information and the freedoms of association, assembly and movement. The Committee interpreted the right to health as an inclusive right extending not only to timely and appropriate health care but also to these underlying determinants of health.

These impose a wide range of positive duties on the state, well beyond the duties of establishing quality and accessible health facilities. For instance, it would need to uphold and enforce labour rights, including ensuring safe and healthy work conditions and preventing occupational diseases and accidents. It would need to ensure that all students live in decent sanitary housing and are able to access clean potable water. It would be required to put into place an elaborate and comprehensive system of social protection, including pensions for older people. It must ensure that populations are not exposed to harmful substances such as radiation and harmful chemicals or to poisoned air and water. The state would need to abolish harmful traditional practices affecting the health of children and women, such as early marriage, female genital mutilation, preferential feeding and care of male children. Children with disabilities should be given the opportunity to enjoy a fulfilling and decent life and to participate within their community.

Excerpted with permission from A Matter of Life and Death: The Unfinished Journey to Secure Healthcare for All, Harsh Mander, Speaking Tiger Books.