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Article

Daniel E. Dawes, Christian M. Amador, and Nelson J. Dunlap

The political determinants of health create the structural conditions and the social drivers—including poor environmental conditions, inadequate transportation, unsafe neighborhoods, poor and unstable housing, and lack of healthy food options—that affect all dynamics involved in health. Globally, recurring examples of the role that these political determinants—through government action or inaction, and policy—are playing in health outcomes and life expectancy, particularly in under-resourced communities, can be observed currently as well as historically. Most notably, the political determinants of health are more than merely separate and distinct from social determinants of health: they serve as the instigators of the social determinants of health with which many people are already well acquainted. They involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities. Focusing on the political determinants of health homes in on the fundamental causes that give rise to, sustain, and exacerbate the social determinants of health that create and worsen the persistent and devastating health inequities that are observed, experienced, researched, and reported. By employing both a theoretical and practical lens to the amelioration of health inequities that continue to pervade communities across the globe, the article contextualizes many of the historic harms that have occurred throughout history, providing a unique perspective on the current state of affairs, and offering a tangible path forward toward a more equitable future. Furthermore, consideration of this new framework at all levels of government as it relates to improving health outcomes for any nation is imperative in order to eliminate existential threats for any and all populations.

Article

Children and adults with intellectual disabilities have poorer health and are more likely to die sooner than their non–intellectually disabled peers. There is growing evidence that some of these inequalities in health are avoidable, unjust, and unfair, given that they are driven by the higher rates of exposure of people with intellectual disabilities to well-established social determinants of poor health. People with intellectual disabilities are more likely than their peers to: live in poverty, not be employed (or if employed to work under precarious conditions), be exposed to discrimination and violence, face significant barriers in accessing effective health care, and be less resilient when exposed to adversities. In other words, they are examples of health inequities that arise from “the societal conditions in which people are born, grow, live, work and age, referred to as social determinants of health. These include early years’ experiences, education, economic status, employment and decent work, housing and environment, and effective systems of preventing and treating ill health” (World Health Organization). Future research needs to address three key issues. First, most of the existing evidence is based on the experiences of people with intellectual disabilities in the world’s high-income countries. In contrast, the vast majority of the world’s population live in middle- and low-income countries. The limited evidence available suggests that children with intellectual disabilities growing up in middle- and low-income countries are much more likely than their peers to be growing up in poverty and to be exposed to specific social determinants of poorer health associated with poverty such as undernutrition, poor sanitation, low levels of parental stimulation, violent parental discipline, and hazardous forms of child labor. Second, little research has focused on health inequalities and inequities among two important groups of people with intellectual disabilities: people with intellectual disabilities from minority ethnic communities and people with mild intellectual disabilities. Third, very little research has attempted to test the proposition that people with intellectual disabilities may be more or less resilient than their peers when exposed to social determinants of health. While much remains to be learned about the inequalities and inequities faced by people with intellectual disabilities, the existing knowledge is sufficient to guide and drive changes in policy and practice that could reduce the health inequities faced by people with intellectual disabilities. These include: improving the visibility of people with intellectual disabilities in local, national, and international health surveillance systems; making “reasonable accommodations” to the operation of health care systems (e.g., introducing annual health checks into primary care services, making “easy read” materials available, employing intellectual disabilities liaison nurses in acute hospitals) to ensure that people with intellectual disabilities are not exposed to systemic discrimination; and ensuring that people with intellectual disabilities (along with all other people with disabilities) are included in and benefit equally from local and national strategies to reduce population levels of exposure to well-established social determinants of poor health.

Article

Occupational health and safety concerns classically encompass conditions and hazards in workplaces which, with sufficient exposure, can lead to injury, distress, illness, or death. The ways in which work is organized and the arrangements under which people are employed have also been linked to worker health. Migrants are people who cross borders away from their usual place of residence, and about one in seven people worldwide is a migrant. Terms like “immigrant” and “emigrant” refer to the direction of that movement relative to the stance of the speaker. Any person who might be classified as a migrant and who works or seeks to work is an immigrant worker and may face challenges to safety, health, and well-being related to the work he or she does. The economic, legal, and social circumstances of migrant workers can place them into employment and working conditions that endanger their safety, health, or well-being. While action in support of migrant worker health must be based on systematic understanding of these individuals’ needs, full understanding the possible dangers to migrant worker health is limited by conceptual and practical challenges to public health surveillance and research about migrant workers. Furthermore, intervention in support of migrant worker health must balance tensions between high-risk and population-based approaches and need to address the broader, structural circumstances that pattern the health-related experiences of migrant workers. Considering the relationships between work and health that include but go beyond workplace hazards and occupational injury, and engaging with the ways in which structural influences act on health through work, are complex endeavors. Without more critically engaging with these issues, however, there is a risk of undermining the effectiveness of efforts to improve the lot of migrant workers by “othering” the workers or by failing to focus on what is causing the occupational safety and health concern in the first place—the characteristics of the work people do. Action in support of migrant workers should therefore aim to ameliorate structural factors that place migrants into disadvantageous conditions while working to improve conditions for all workers.

Article

Gerard Bodeker and Kishan Kariippanon

An estimated 370 million Indigenous people reside in 90 countries and make up 5% of the global population. Three hundred million Indigenous people live in extremely disadvantaged rural locations. Indigenous people have suffered from historic injustices due to colonization and the dispossession of their lands, territories, and resources, thus preventing them from exercising their right to development according to their own needs and interests. Across the board, Indigenous people have poorer health outcomes when compared to their non-Indigenous fellow citizens. Cancer, respiratory disease, endocrine, nutritional, and metabolic disorders, primarily diabetes, affect Indigenous people disproportionately. Newborns of Indigenous women are more than twice as likely to be of low birth weight as those born to non-Indigenous women. Indigenous rates of suicide are the highest in the world. For public health to be effective, a social determinants approach, along with health interventions, is insufficient to create lasting health impact. Partnerships with Indigenous organizations, Indigenous researchers, and the professionalization of health workers is essential. Integration of traditional medicine and traditional health practitioners can enable the Western biomedical model to work in partnership with Indigenous knowledge systems and become more locally relevant and accountable. The Indigenous health workforce is increasingly using evidence-based, innovative approaches to address the shortage of health professionals as they move toward universal health coverage. Internet, mobile, and communication technologies are enhancing the mobilization of Indigenous health efforts and the support for health workers in rural locations. Presented are country examples of integrated medicine and Indigenous partnerships that effectively implement health interventions.

Article

Marco Akerman, Gabriela Murillo Sancho, and Samuel Jorge Moysés

Cities have been considered in many places and times a cornerstone of innovation and wealth creation in society, fostering the privilege of more comfortable lives, with existential dignity and producing healthier generations, as well as an important source of pathogenic determinants. The concept of health in cities and its intersectoral relationships unfolds in a new era of urban sociability, mediated by technologies that connect citizens in social networks and in many services provided by digital platforms. All changes have their respective economic and cost-effective impacts. Healthy cities, or smart and sustainable cities, intend to express well-being and the fulfillment of good health among people who enjoy social inclusion, effectively using policies and services concentrated in the most developed cities. However, the extent of the challenges that permeate the current urban civilization cycle is also related to the social inequities manifested in health problems and public mismanagement in cities around the world. It is necessary to think about the integration of the intersectoral habitus of conceptualizing health promotion, considering all its inclusive scope of diversity, without leaving any social and identity group out, with a view to the full realization of healthy cities. There is an ethical, political, and cultural imperative to urgently adopt an ecosocial approach to promoting the health of populations in cities around the world, recognizing the interactions between ecological determinants (all planetary systems and living species) and the very internal dispositions of what constitutes human health.

Article

Kira Fortune, Francisco Becerra, Paulo Buss, Orielle Solar, Patricia Ribeiro, and Gabriela E. Keahon

There is a broad consensus that the health of an individual or population is not influenced solely by the efforts of the formal health sector; rather, it is also defined by the conditions of daily life as well as the inputs, intentional or not, of various stakeholders and policies. The recognition that health outcomes and inequity in health extend beyond the health sector across many social and government sectors has led to the emergence of a comprehensive policy perspective known as Health in All Policies (HiAP). Building on earlier concepts and principles outlined in the Alma-Ata Declaration (1978) and the Ottawa Charter for Health Promotion (1986), HiAP is a collaborative approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. Health in All Policies has become particularly relevant in light of the adoption of the 2030 Agenda for Sustainable Development and the 17 Sustainable Development Goals (SDGs), as achieving the goals of the agenda requires policy coherence and collaboration across sectors. Given that local governments are ideally positioned to encourage and galvanize partnerships between a diversity of local stakeholders, the implementation of HiAP at the local level is seen as a powerful approach to advancing health and achieving the SDGs through scaled-up initiatives. As there is no single model for the development and implementation of HiAP, it is critical to examine the different experiences across countries that have garnered success in order to identify best practices. The Region of the Americas has made much progress in advancing the HiAP approach, and as such much can be learned from analyzing implementation at country level thus far. Specific initiatives of the Americas may highlight key examples of local action for HiAP and should be taken into consideration for future implementation. Moving forward, it will be important to consider bottom up approaches that directly address the wider determinants of health and health equity.

Article

Being physically active and eating fresh foods could reduce the growing burdens of cardiovascular disease, cognitive decline, obesity, some cancers, diabetes type II, depression, and anxiety. Increasing these health behaviors has been a public health focus for decades, yet over one half of adults around the world remain insufficiently physically active and four in ten are overweight or obese. When people are asked why they don’t exercise more or eat healthy food, the most common reason they give is lack of time. Everyone has 24 hours in a day, so why do so many people say they lack time to be healthy? Time is a challenging (and intriguing) concept. Usually, time is thought about in terms of hours and minutes which evenly divide a day, and its lack a consequence of misguided priorities. This assumes that all hours are equal and available for use and that every person has agency over their time. Although having sufficient time is fundamental to health (exercising, preparing healthy food, resting, accessing services, and maintaining social bonds all take time), other dimensions such as control, flexibility, intensity, and timing are essential for understanding how time and health are connected. Like income, time is exchanged and given within households, so it can be fruitful to view time as a household resource rather than an individual’s resource. In the labor market, time is exchanged for payment, and this underscores time’s potency as a social and economic resource. Historically, research on the social determinants of health and health equity have focused on the harms linked to work hours, including the length and timing of the work day and flexible hours. Yet this research missed the importance of time outside the labor market, which alters the health consequence of work hours, delivering only a partial analysis of how time shapes health. Research since the early 2000s is supplying new evidence of the interplay between work, care, and other non-market time, allowing a more accurate insight into how time shapes health and how this relationship connects to social and gender equity. Debates remain, however, and these include the extent to which time pressure and time scarcity are problems of motivation and perception and whether time scarcity is a problem of only the affluent. There are precedents to address time costs and inequities. A first step for health prevention and health promotion practitioners is to value time in ways comparable to how the field values money. This would mean limiting the time costs of health interventions and services, including the requirement to “find time” outside of work or care roles to be healthy. The field also needs to challenge the idea that the income-poor are time-rich since this is rarely the case if they are caregivers. As well as minimizing time burdens, policies to address the social determinants of time from urban planning, transport systems, and work-hour regulations will be critical to achieving a fairer and healthier world.

Article

Compared to the general population, people with intellectual and developmental disabilities (IDD) face worse health outcomes, and outcomes are even worse for children and adults with IDD from minoritized populations. Examining the intersection of people with IDD from minoritized groups is critical to understanding appropriate policies and services that promote health among all people with IDD. People with IDD from minoritized racial and ethnic groups have greater exposure to detrimental social determinants of health, which leads to poor access to adequate healthcare and poor health outcomes. Policies that aim to improve health outcomes among people with IDD and that are related to their disability and appropriate accommodations are not enough. Policies need to address poverty in families, racism and discrimination, poor housing, and other social determinants that are more prevalent among minoritized populations. Most research on racial and ethnic disparities among children and adults with IDD has been conducted in the United States. While there is emerging research globally on racial and ethnic disparities, there a paucity of this research in the field of IDD. Furthermore, there may be detrimental health effects for other minoritized groups, such as religious minorities, but research is lacking in this area. Clearly, more research on these intersections is needed in the global context.

Article

In 1978, at an international conference in Kazakhstan, the World Health Organization (WHO) and the United Nations Children’s Fund put forward a policy proposal entitled “Primary Health Care” (PHC). Adopted by all the World Health Organization member states, the proposal catalyzed ideas and experiences by which governments and people began to change their views about how good health was obtained and sustained. The Declaration of Alma-Ata (as it is known, after the city in which the conference was held) committed member states to take action to achieve the WHO definition of health as “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Arguing that good health was not merely the result of biomedical advances, health-services provision, and professional care, the declaration stated that health was a human right, that the inequality of health status among the world’s populations was unacceptable, and that people had a right and duty to become involved in the planning and implementation of their own healthcare. It proposed that this policy be supported through collaboration with other government sectors to ensure that health was recognized as a key to development planning. Under the banner call “Health for All by the Year 2000,” WHO and the United Nations Children’s Fund set out to turn their vision for improving health into practice. They confronted a number of critical challenges. These included defining PHC and translating PHC into practice, developing frameworks to translate equity into action, experiencing both the potential and the limitations of community participation in helping to achieve the WHO definition of health, and seeking the necessary financing to support the transformation of health systems. These challenges were taken up by global, national, and nongovernmental organization programs in efforts to balance the PHC vision with the realities of health-service delivery. The implementation of these programs had varying degrees of success and failure. In the future, PHC will need to address to critical concerns, the first of which is how to address the pressing health issues of the early 21st century, including climate change, control of noncommunicable diseases, global health emergencies, and the cost and effectiveness of humanitarian aid in the light of increasing violent disturbances and issues around global governance. The second is how PHC will influence policies emerging from the increasing understanding that health interventions should be implemented in the context of complexity rather than as linear, predictable solutions.