HIV/ AIDS and Health Determinants: Lessons for Coordinating Policy and Action

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A Discussion Paper for the Ministerial Council on AIDS

2. From Medical Care to Social Care

The concept of health has evolved very considerably through the past decades. Whereas historically health in Canada was associated with medical care and treatment, more recently there has been a much fuller appreciation of how social and economic factors influence the health of individuals and communities.

2.1 Health Promotion

In Canada, the literature often identifies the Lalonde Report ⁶ ( 1974) as a watershed in terms of shifting the public policy debate on health:

• away from a reliance upon medical treatment and the health care system; and
• toward an emphasis on building healthy communities and on individual and community responsibility for their own health and well being.

This concept was promoted in the Achieving Health for All report and the Ottawa Charter for Health Promotion ( 1986) . The latter was internationally recognized as both a standard and a foundation for health promotion efforts. It suggested that governments could improve public health by building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and redirecting health services so as to place less emphasis on residual care and more on preventing disease. ⁷ Some sources suggest that the Ottawa Charter included peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity as important health prerequisites. ⁸

Health promotion combined this broad perspective with a behavioural approach that focused on individuals and groups. It is described as the science and art of helping people change their lifestyle to move toward a state of optimal health. ⁹ Lifestyle change, it suggests, can be facilitated through a combination of efforts to enhance awareness, influence behaviour and create environments that support good health practices. The concept emphasizes the active role of the individual as an agent of change." ¹⁰

The health promotion concept dominated early efforts to address the HIV/ AIDS epidemic. However while government and community agencies understood the importance of broad societal change, prevention strategies were more narrowly focused. Roy Anderson and his colleagues, for example, suggest that the risk of HIV infection in this period was defined according to mode of transmission. As a result, public health funding, prevention programmes and surveillance activities targeted specific risk groups or categories, such as injection drug users, men who have sex with men, and haemophiliacs, and focused on specific behaviours. ¹¹

 

Prevention efforts focused on changing personal behaviour and on encouraging people, often through a community development approach, to adopt lifestyle practices that reduced their risk of infection. The HIV/ AIDS experience illustrated not only the potential impact of this approach but also its shortcomings:

• first, the focus on mode of transmission ignored the needs of those who do not fit neatly or identify themselves as fitting into these transmission categories or who are vulnerable to HIV because of wider socio-economic, cultural and political factors; ¹² and
• second, the exaggerated emphasis on lifestyle as a determinant of health [ had an ] implicit tendency to blame the victim. ¹³

Critics suggested that the health promotion approach conceived of individual lifestyles as existing in a vacuum. They also suggested that its popularity derived from its congruence with the traditional medical model, wherein causal biologic pathways can be hypothesized and high-risk people individually managed by health providers. ¹⁴ Society, seemingly, had little responsibility for the choices made by individuals.

2.2 Population Health

In the 1990s, the research and government communities endeavoured to re-affirm the broader roots of the health promotion concept. While certainly not neglecting individual behaviour and vulnerable groups, they began to emphasize the larger social system within which people lived and worked. This approach offered considerably more promise for beneficial change ¹⁵ by emphasizing that social environments have a far stronger impact on health than [ does ] individual behaviour. ¹⁶ This approach was well suited to the changes evident in the HIV/ AIDS epidemic during that decade, namely its proliferation among widely diverse populations.

In 1994, federal, provincial and territorial Ministers of Health officially endorsed the population health concept in a major discussion paper, Strategies for Population Health: Investing in the Health of Canadians This was followed by two major reports measuring the health status of Canadians ( 1996 and 1999) , a position paper Taking Action on Population Health ( 1998) and The Population Health Template: A Framework to Define and Implement a Population Health Approach ( 2001) .

 

These reports represented an important commitment to the population health model and to research and monitoring. ¹⁷ This emphasis reflected government concern with ever-increasing costs within the health care system and reflected also the need to promote health rather than treat illness.

The goals of the population health model were:

• to maintain and improve the health of the entire population; and
• to reduce inequities in health between population groups.

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The decline in mortality since 1900 was the result more of improvements in the social and physical environment than of advances in medical care. In fact, most new interventions, including therapeutic drugs, immunizations and surgical procedures were introduced several decades after a marked decline in mortality from those diseases had already taken place. Auerbach, 2001: 3

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This concept takes into account the entire range of factors and conditions that influence health as well as the interactions among them. It acknowledges that many of these factors and the most important of these factors lie outside the health care system. ¹⁸

Initially community-based HIV/ AIDS organizations were uneasy with the population health concept suggesting that it:

• did little to recognize the importance of individual and community-based initiatives designed to prevent the epidemic s spread and to care for those living with the virus;
  
• did not recognize the tremendous diversity that existed within both the general and the at-risk populations; and
  
• was a largely top down approach that relied upon social and economic policy initiatives that did not adequately consider the personal, group and community development [ activities that ] often come from the affected communities themselves. ¹⁹

Additionally, many groups believed that the population health approach offered little for the short term or for actual field practice. Furthermore, its goals required consistent, coordinated and sustained efforts involving a broad range of governments, agencies and sectors. This requirement presented a formidable barrier to progress.

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In the first decade of the HIV epidemic, researchers focused on sexual and drug using behaviours which directly related to the risk of HIV infection. Now that we are well into the second decade, our attentions have turned to the reasons for these behaviours .... Strathdee, Social determinants related ..., 1997: 2

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2.3 The Social Determinants

The population health approach emphasizes those social determinants that influence individual and community health.

There has been very considerable discussion around which determinants or which groups of determinants contribute to population health. In 1994, for example, the Federal/ Provincial/ Territorial Advisory Committee identified social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development and health services. ²⁰ The Second Report on the Health of Canadians identified income, education and working conditions. ²¹ Elsewhere Health Canada added social status, social support networks, employment, physical environments, social environments, biology and genetic endowment, personal health practices and coping skills, healthy child development, health services, gender and culture.²² Hayes and Glouberman, meanwhile, emphasized early childhood experiences, social and economic gradients, work and working conditions, and social networks and supports.²³

The list of determinants is broad and comprehensive, and can be summarized as follows:

• income and the economic environment for example employment, education,
  absolute and, more importantly, relative poverty;
  
• the social environment and social status for example social support networks, perceived control over one s life and exposure to discrimination;
  
• the physical environment for example homelessness, housing adequacy and neighbourhood safety;
  
• early childhood experiences for example education, nourishment and sexual, physical or emotional abuse;
  
• cultural or community factors including personal health and sexual practices, gender, race, community pressures and behaviours, biology and genetic endowment; and
  
• health services for example access to culturally and gender-appropriate services and equitable access to prevention, care, treatment and support services.

 

This list of potential determinants reflects not only the reality and complexity of life but also the effort to explore every possibility. This has several consequences:

• first, everything every experience and every factor at every time throughout one s life is described as having an impact on health. The literature rarely endeavours to determine the relative importance of each and only infrequently notes the association among the different social determinants.
  
• second, the concept remains poorly understood and different individuals and organizations use the language of population health while having very different concepts of what it means for public policy and programs. Thus it is difficult for organizations to communicate with each other and to agree on priorities.

There is not at present a clear understanding that, very simply, individual and population health are determined by a wide variety of factors acting singly and together. And that a diverse array of efforts are required to improve health and well being.

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6 Health and Welfare Canada, A New Perspective on the Health of Canadians, 1974.
7 Hayes and Glouberman, 1999: 6.
8 AIDS Vancouver, 1997: 1-2.
9 American Journal of Health Promotion, 1989.
10 Canadian Public Health Association, 1997: 8. 14
11 Anderson, 1999: 8.
12 Ibid. , 8.
13 Hayes and Glouberman, 1999: 4-5.
14 McKinlay, 1993: 109.
15 Ibid. , 110.
16 Glouberman, 2001: 22.
17 Health Canada, Population and Public Health Branch, 2001, The Population Health Template.
18 Guildford, 2000: 5. See also Canada, Health Canada, 1998, Taking Action on Population Health.
19 Canadian Public Health Association, 1997: 7. 16
20 Canada, Health Canada, The Population Health Template, 2001.
21 Federal/ Provincial/ Territorial Advisory Committee on Population Health, 1999.
22 Canada, Health Canada, Taking Action on Population Health, 1998. See also, Guildford, 2000: 5.
23 Hayes and Glouberman, 1999: 7-8. 17

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