American Journal of Law & Medicine

Beyond Lifestyle: Governing the Social Determinants of Health

Non-communicable and chronic diseases have overtaken infectious diseases as the major causes of death and disability around the world. Despite recognition that reduction in the chronic disease burden will require governance systems to address the social determinants of health, most public health recommendations emphasize individual behavior as the primary cause of illness and the target of intervention. This Article argues that focusing on lifestyle can backfire, by increasing health inequities and inviting human rights violations. If States fail to take meaningful steps to alter the social and economic structures that create health risks and encourage unhealthy behavior, health at the population level is unlikely to improve significantly. Viewing the global health challenge from the perspective of human rights, however, reveals opportunities for positive change in all sectors of governance. Explicit recognition of human rights can help refocus attention on the fundamental causes of health and protect individuals from unnecessary harm.

I. INTRODUCTION
II. THE BURDEN OF DISEASE GLOBALLY AND IN THE UNITED STATES
III. FUNDAMENTAL CAUSES OF DISEASE
IV. FUNDAMENTAL CAUSES AND LIFESTYLE INTERVENTIONS
V. FROM INDIVIDUAL HEALTH TO THE FUNDAMENTAL CAUSES OF
   HEALTH AND EQUITY
    A. A HUMAN RIGHTS APPROACH
VI. INFECTIOUS DISEASES DEMAND ATTENTION
VII. CONCLUSION

I. INTRODUCTION

Global systems of health governance were first developed to combat the spread of infectious diseases across national boundaries. (1) Infectious diseases may always be with us, but they are no longer the predominant threat to public health that they were historically, neither in developed democracies, nor in developing countries. (2) Successes in controlling and treating infectious diseases have resulted in non-communicable and chronic diseases becoming the leading causes of mortality for most of world's population. Despite increasing recognition of the global burden of chronic disease, effective steps to prevent or mitigate this burden have been scattered and limited. (3) Perceived dangers of pandemics, such as SARS, influenza, Ebola, and Zika, (4) periodically capture international attention and distract attention from more persistent threats to population health. (5)

To a noticeable extent, global recommendations to prevent non-communicable and chronic diseases have followed the global public health model for containing infectious disease by targeting individual behavior or lifestyle as a primary cause of illness and a locus for intervention. (6) This Article argues that this approach is not well suited to the task. Rather, it often fails to alter the fundamental causes of behavior and also risks violating human rights. If the goal of global health governance is to improve health and human flourishing, as this Article believes it is, or should be, then more robust efforts are required to address the fundamental causes of chronic diseases; namely, policies and programs to improve the social determinants of health. (7) The need for such efforts can be seen by viewing global health goals through the lens of human rights, which recognizes State responsibilities for protecting both public health and individual freedoms. (8)

This Article begins with a brief description in Part II of how non-communicable and chronic diseases have overtaken infectious diseases as the major sources of death and disability around the world. Part III describes the social determinants of health--social, economic, educational, environmental, political, and cultural conditions in which people live and work--which are the fundamental causes of mortality and morbidity. Part IV argues that efforts to address social causes remain inadequate, in part because they focus heavily on individual lifestyle and personal behaviors rather than the deeper fundamental causes. Part V argues that significant improvements in global population health are unlikely to materialize unless governance systems in all sectors recognize how their respective policies and activities affect the social determinants of health. Epidemics of communicable diseases, however, frequently disrupt sustained attention to fundamental causes of chronic disease, as discussed in Part VI. The Article concludes that because global health goals reflect human rights, national and international commitments to respect, protect, and fulfill human rights also have the potential to improve global health. Explicit recognition of human rights can help refocus attention on fundamental causes of health and protect individuals from unnecessary harm.

II. THE BURDEN OF DISEASE GLOBALLY AND IN THE UNITED STATES

Chronic diseases have surpassed communicable diseases as the leading causes of death, not only in high-income countries, but also around the world. (9) Global Health Observatory data for 2012, shown in Table 1, report that the leading causes of death globally were ischemic heart disease, stroke, chronic obstructive pulmonary disease and lower respiratory infections. (10) Chronic and non-communicable diseases accounted for an estimated thirty-eight million (about sixty-eight percent) of the total fifty-six million deaths worldwide in 2012. (11) This represents an increase in the proportion of deaths attributable to chronic diseases since 2005, when the World Health Organization (WHO) estimated that thirty-five million (sixty percent) of the fifty-eight million deaths from all causes around the world resulted from chronic diseases. (12) That was "double the number of deaths from all infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and perinatal conditions, and nutritional deficiencies combined." (13) This trend is likely to continue, even if the estimates are based on highly imperfect data. WHO projects that deaths from chronic diseases may increase to fifty-two million by 2030. (14)

In 2012, the top three causes of death in low-income countries were lower respiratory infections, HIV/AIDS, and diarrheal diseases. (16) In the rest of the world, however, heart disease and stroke were the top two causes. (17) About seventy-five percent of deaths from chronic diseases were in low-middle income countries, affecting men and women about equally. (18)

In one sense, the rising proportion of deaths from chronic diseases might be good news. The data suggest that as countries improve their economies, deaths from infectious diseases may decline. (19) This could also indicate that people are living long enough to acquire a non-communicable disease. Life expectancy is increasing, (20) and scientific advances have converted some formerly fatal infectious diseases, like HIV, into manageable chronic conditions, at least for more affluent populations. (21) But, in some circumstances, a quick death from a heart attack or stroke may be preferable to years of pain or inability to function. (22) Chronic diseases often come with disabilities that make life difficult, undermining the value of longevity. (23) About one billion people--fifteen percent of the world population--have disabilities from a variety of causes, including health conditions, injuries, and genetics. (24) Between 110 and 190 million people over fifteen years of age have difficulty functioning, especially those with chronic diseases, and this number is expected to grow. (25) Moreover, disabilities affect family members, who often experience stress as well as loss of income. (26) Rapid aging of the population, currently increasing at 3.26% per year, will intensify these problems and likely dampen economic growth. (27) Europe currently has the largest percentage of elderly at twenty-four percent of the population, and it is estimated that by 2050, about one quarter of the populations in all areas of the world except Africa will be age sixty or older. (28)

All this is to suggest, as international organizations and commentators recognize, that efforts to improve global health should pay more attention to the causes of chronic conditions. (29) The global burden of disease has not only shifted from communicable to chronic, but population health concerns have also shifted from premature deaths to increased years of life lived with disabilities. (30) Because chronic diseases both cause poverty and stifle economic development, which in turn cause illness, disability, and death, improving health can create a positive feedback loop with improving economic development. (31)

III. FUNDAMENTAL CAUSES OF DISEASE

What causes all this illness, injury and disability? In the field of global health and public health generally, there is widespread recognition of the social determinants of health--the social, economic, educational, environmental, political and cultural conditions that influence the health of populations. (32) When Canadian Minister of National Health and Welfare, Marc LaLonde, introduced the Health Field Concept in 1974, he identified four main influences on health: human biology; environment; lifestyle; and healthcare organization. (33) The 1978 Declaration of Alma Ata stated, "Governments have a responsibility for the health of their people, which can be fulfilled only by the provision of adequate health and social measures." (34) In the decades since, countries have paid increasing attention to healthcare services emphasized by Alma Ata, including primary care. (35) But healthcare services alone cannot remove all the causes of disease or injury. Both the Millennial Development Goals and the more recent Sustainable Development Goals call for action on a variety of social determinants of health. (36) The United Nations Conference on Sustainable Development, known as Rio+20, concluded that "health is a precondition for and an outcome and indicator of all three [economic, social, and environmental] dimensions of sustainable development." (37) The literature has also fleshed out elements in the social, economic, and physical environment, including political inequality, that affect population health outcomes. (38)

These social and environmental systems and policies have been called fundamental determinants of health and illness because they define the opportunities and obstacles facing individuals. (39) These fundamental causes are also sometimes called distal or upstream drivers because they can filter through multiple pathways to expose people to health risks, influence behavior, affect access to care, and ultimately result in particular health outcomes. (40) Importantly, the complex, iterative processes whereby these causes interact can mitigate or enhance their effects. Examples are legion. Wealth enables a good education, which in turn facilitates well-paying employment and well-constructed housing in a safe community, free from pollutants, with access to good nutrition. (41) In contrast, young children living in poverty may be exposed to poor nutrition, violence, or toxic substances, such as lead, risking brain damage that impedes their development and educational opportunities. (42) Climate change affects access to potable water and sanitation, as well as what crops can be grown. (43) Access to water can influence opportunities for education and income, which affect health status. (44) Urbanization may destabilize the accessibility and affordability of necessaries, such as clean water, adequate housing, safe food and employment. (45) Current estimates suggest that by 2050, sixty-six percent of the world's population is expected to be urban, with Africa and Asia urbanizing at faster rates than other regions. (46) Discrimination on the basis of race, color, religion, sex or gender circumscribes opportunities for targeted populations in education, employment and housing, which undermines health; and discriminatory practices in the healthcare system can hinder access to the treatment that is needed as a result. (47) Political equality and education for women and girls is linked to improved population health and economic growth. (48) And poverty, possibly the most significant contributor to health disparities, is intertwined in complex ways with most of these other factors. (49)

[FIGURE 1 OMITTED] (50)

Attempts to express these relationships visually can be challenging. For example, Dahlgren and Whitehead's depiction in Figure 1 above, which has been widely adopted and adapted, flattens the factors into spatial levels suggesting separate spheres. Figure 2 below attempts to illustrate some of the interactions among factors affecting health, suggesting forward movement from structural to intermediate factors without recognizing all of the circular dynamics that occur in reality.

[FIGURE 2 OMITTED] (51)

Nancy Krieger points out that categorizing health risk factors as distal/upstream and proximal/intermediate/downstream fails to capture the dynamic interaction among these factors. (52) It is true that such labels can imply uni-directional pathways, instead of the looping, iterative processes in which factors interact. Moreover, categorizing social and economic factors as distal suggests that they are far removed in time from, and therefore have less causal influence on, health outcomes than proximal factors. The reverse is sometimes true. Laws and policies that appear on the distal end of the visual spectrum can directly affect individuals in ways that prejudice their health. For example, laws governing conditions of employment can directly affect worker health, and policies governing health insurance coverage may directly affect access to necessary care. (53) The introduction of unaffordable fees for privatized water systems can make it impossible for poor families to have enough water for drinking, much less sanitation and hygiene. (54) And policy failures, such as Flint, Michigan's decision to change its water supply, can cause contamination and illness in the population served. (55)

Determining how to define health status can further complicate the picture. A person's health is rarely the dichotomous presence or absence of disease. (56) One's health status changes from time to time during one's life. Thus, the concept of health itself is evolving to include formulations such as well-being throughout the life course or the "ability to adapt and self manage." (57) This more flexible concept of health as well-being fits nicely with evaluations of chronic diseases and conditions, since some people are better positioned to adapt successfully to particular disabilities than others. Those with sufficient income, education, access to healthcare, and social support systems are more likely to function well with disabilities than those without these advantages. Thus, successful adaptation is likely to depend on social determinants of health; that is, the social, economic, political, and cultural systems, policies, and laws that make these advantages available. The development of a life course perspective on health enables researchers to identify the cumulative and interactive effects of these influences on health. (58)

Many factors that contribute to the relative rise in chronic diseases, as well as the persistence of many infectious diseases, have social and economic origins. (59) Perhaps most influential is poverty. (69) Low-income populations, especially the urban poor, live in the unhealthiest environmental conditions. (61) The United States recession worsened the plight of the urban poor with the loss of job opportunities. (62) The World Bank and the International Monetary Fund's insistence on "austerity" measures exacerbated unemployment in other developed countries with national debt and created multiple stresses on the populations affected. In undeveloped nations, migration out of war zones, like Syria, compounded so-called economic migration from one country to another. (63) In addition, trade policies may also affect health. For example, the reduction in trade barriers encouraged by the General Agreement on Trade and Tariffs (64) allowed relaxation of laws governing the quality of health services and the environment, as well as trade in firearms, alcohol, and tobacco. (65)

Programs intended to address critical national problems in low-income countries are sometimes squeezed out by donor-driven policies that target specific diseases. …

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