2014: Year of the Social Determinants of Health?

The following two tabs change content below.
Kenny Pettersen

Kenny Pettersen

Kenny Pettersen holds a Master of Public Health and is currently finishing medical school at UC San Francisco. He has worked extensively in Haiti since 2004 and among homeless populations in the US. He is particularly interested in improving chronic disease management through health systems strengthening efforts, such as eHealth and health workforce development.

As I reflect on the major events of 2014, I’m surprised by the underlying themes of social inequality and a global desire to do things better. As a public health practitioner and soon-to-be minted medical doctor, I’m constantly considering the ways in which these events lend insight into the social determinants of health.

There are at least three themes that caught my interest, which I wish to reflect on here: Ebola, racial & LGBT inequality, and violence against women & children. I’ve included useful links in case you’d like to read more about particular stories.

Ebola, Public Health, and Health System StrengtheningEbola_outbreak_in_Gulu_Municipal_Hospital-2

Despite countless outbreaks since the 1970’s (see the Hub’s Ebola Timeline here), the largest epidemic on record is ongoing in West Africa (latest reports of over 6,500 deaths). Experts agree that a lack of investment in underlying health systems infrastructure is a fundamental reason, perhaps complicated by growing urbanization. But as one Global Health Hub contributor pointed out, “Why did it take an Ebola outbreak for us to realize the importance of health systems”?

My discussions with one medical volunteer, who recently returned from Liberia, unveiled the tremendous influence of post-colonialism on this modern-day event. With the slave trade originating in West Africa, the effects of colonial rule continue to impact the region. Interestingly, current epidemiological measurements suggest that the ongoing Ebola outbreak is subsiding in Liberia while persisting in Sierra Leone and Guinea. Liberia has colonial roots with the United States, benefitting from strong coordination with the CDC and other critical US agencies. Sierra Leone, on the other hand, is rooted in British rule while GuineaSlave_Auction_Ad with the French. As of October 28, 2014 (per the
Guardian Ebola funding tracker
), the US government delivered $575 million while the UK and France delivered just $222
million and $108 million respectively (though each country has smaller populations). Allocations for September were $473 million for Liberia, $220 million for Sierra Leone, and $57 million of Guinea. These relationships would appear to at least partially explain why the Liberian outbreak, though initially the worst, has experienced the most significant gains.

Social determinants were also exposed in the United States, where Liberian citizen Thomas Duncan was the first to be diagnosed with Ebola and ultimately succumbed to the disease. Multiple questions were raised from his death: Why was he initially turned away from care? Why did he die and others with Ebola in the US survive? The cynics among us would point out the ugly realities: Thomas Duncan was a person of color, uninsured, and foreign. Further unsettling is the other death in the United States: US resident and Sierra Leone native, Dr. Martin Salia. Though both Salia and Duncan’s deaths were ultimately due to delays in care and the high viral load they were exposed to, one wonders if their fate would be different if they were white and socially connected?

Racial and LGBT Inequality

This year, decades of post-civil rights era racial inequality came to a head through the high-profile killings of young, African American men by white police officers in FergusonStaten Island, and Cleveland. The #BlackLivesMatter campaign and country-wide protests shed light not only on specific instances of racial discrimination but also on the systematic exclusion of people of color throughout our societies.

LGBT communities across the world also faced serious threats. In February of this year, Uganda enacted an “Anti-Homosexuality Act”, threatening a lifetime imprisonment for “acts of homosexuality”. Though the bill was later annulled by Ugandan courts, politicians are actively advocating for new legislation with similar aims. Media coverage of LGBT issues extended to Russia, which was heavily criticized for anti-LGBT rights during its hosting of the 2014 Winter Olympics.Antiwar_Democratic_March_in_St._Petersburg_on_1_May_2014_(100_3452)

These troubling events highlight key disparities in race and sexual orientation. Though we shouldn’t forget areas of important progress, we must remember the tremendous gap in social equity and its detrimental health consequences. The life expectancy for blacks in the US, for example, is 30 years behind that of whites. Despite recent advances in US legislation, LGBT communities continue to face higher burdens of chronic disease and mental illness, while often receive substandard medical care.

Violence against women & children

Earlier this year, we were horrified to learn of the kidnappings and enslavement of young school girls in Nigeria. Perhaps more worrisome was the emergence of ISIS, which was highlighted after brutal killings of US citizens on YouTube; the most appalling actions, however, surrounded the mass killings of minority populations and the enslavement of women and children in Iraq and Syria. Just this week, we watched in horror as Pakistani school Michelle-obama-bringbackourgirlschildren were massacred by the Taliban. The long-term societal effects of such brutality are difficult to ponder.

The nexus for much of the violence surrounds the deeply held belief by some factions that women should not participate in education. Yet, we know that some of the most profitable social investments (including tremendous health yields) may be achieved if educate our children and empower our women. So much so, in fact, that donors, such as the Gates Foundation, have made this a pillar of global development. Thankfully, this trend appears to be growing and will likely continue to remain a key component of the UN’s 2015 Sustainable Development Goals.

2015 and Beyond

As we look forward to a new year, may we continue to reflect on events that lend insight into upstream influences of health and well being. Moreover, let’s strive for social change that truly transforms lives and advances health equity for all.

Despite many seemingly negative stories reflecting our shortcomings, we should also remember the victories. Bill Gates, for example, now writes an annual “Good News You May Have Missed…” blog. These successes should inspire us to be better as individuals, communities, and societies, ultimately being “the change [we] wish to see in the world.”